Manuals, Handouts, Sticky Notes & Lists

My father was a story teller. We lived in a tiny town called Alleppey in South India. As a result of its canals and bridges that were used for the spice trade, Alleppey was also called the “Venice of the East”. Every morning , my father went into town to pay bills and buy groceries. He loved people and talking. And everyday he returned from these forays with simple humourous stories about the townspeople, the various bridges and his minor adventures. It was an experience.

In his youth, my father left his tiny village to get on a ship and travel to Abadan ( Iran) in 1942 for work. It was the middle of the Second World War. India was in the last years of British Rule. I learned to be curious about the bigger world through my father’s stories. In the days of my childhood, before Google, in my tiny town that had no English library or bookstore, my father’s stories about Hitler and Gandhi and Jesus and Mandela kept me connected to things outside my geographical limitations. I learned the value of presence and good story-telling. It is an easy, collaborative side-door into perspectives, ways of being, teaching and learning. It is entertaining, creative and “being with” at its best. Both children and adults listen, hear and reflect automatically and respond with curiosity. One does not have to work too hard to get a point across.

We have come a long way from this kind of easy learning. Therapy is not understood as a conduit to learning a new way of being. In a culture of “fixing”, one is ‘broken’ and one goes to therapy to get fixed. One does not seek out therapy unless one’s life in interrupted terribly. And then we are in a hurry to get fixed and “move on”. I am not suggesting that therapy is vague story-telling. However ……………. in his research on therapeutic processes, Scott Miller names the therapist-client relationship as the most important factor that influences and encourages change. The co-regulating value of being present with another should not be underestimated. “Being with” should not be sacrificed to simply “doing”.

The advent of manualized models into the therapy room has posed a challenge that is not yet named as a handicap in the world of therapy. Convenient therapy vs. therapy that actually paces with the client. Being in the same room does not translate to “being with” that makes a difference. Parenting also struggles with the same challenge - Parent-orietned parenting ( i.e. “Let the child cry it out”) vs. Child-oriented parenting ( “Children will if they can” ). Children and clients are inconvenient. They do not often move at a desired or convenient pace. It seems to be fairly obvious that if one were to take on the jobs of being a parent or a therapist, one must have calculated the cost of this choice. It will come as a surprise that people often do not consider that children and clients do not subscribe to plans that are made without considering them. Parents and therapists are surprised and irritated when their best- laid intentions do not work out. We then desperately resort to behavioural interventions that promise results. Behavioural researchers are people who have decided that emotions are too inconvenient and we can get around them with the employment of rewards and consequences. Caretakers are wooed into the magic of concrete , measureable outcomes and assume that everyone is in agreement.

Enter the manual into the world of therapy. A book of instructions and “strategies” that the client can do when they are dysregulated, to regulate themselves. A concrete solution that both the therapist and the client can touch and hold onto, in their moments of anxiety. A tangible solution to that pesky intangible thing - anxiety. Anxiety LOVES paper. An anxious client likes nothing more than a piece of paper to not experience the anxiety in the therapy room. A person struggling with OCD loves making lists. I have seen clients make extremely long pros-and-cons lists that lead to no conclusion at all. By the same token, an anxious therapist can love nothing more than a manual that has a hundred exercises that can be shared with the client in a hundred sessions. So, why doesn’t it work? Why does every client have binders lying around their home, full of skills that do not help in the urgency of the moment?

It is not the manual’s fault. The manual is , indeed, full of helpful strategies. However, what the client has missed in their life is the experience of effective “co-regulation” and “being with”. In the place of what did not happen exists dysregulation and isolation. Children learn to be ashamed of their inconvenient emotions. An adult woman starts crying in my office and mutters “I am SO weak!” The manual has inadvertently invited therapists to forget their presence and creativity in the therapy room. What would therapy look like if the manual stayed in the therapist’s home as a guide to a collaborative experience in the therapy room with the client? What would practicing the skill “in the room” look and feel like? There is a difference between talking about emotions and actually allowing it to exist in the room in real time. Evoking and experiencing the scary emotion in the room , riding the wave with a trusted therapist and learning how to stay present in one’s own body is the stuff of good therapy. The therapist is a brave collaborator in this new experience who promises that one can survive the terrible ‘fight-flight’ sensation in one’s body. It follows that the therapist has to be a practiced expert in these skills in their own lives. One cannot teach Spanish without knowing it inside out. It is dangerous to propose “radical acceptance” without knowing the difference between acceptance and resignation. The skills in the manual do well when couched within the regulation and validation of the therapeutic relationship. When the client stands on the broad trusting ground of the therapist’s presence, creativity and humour, any skill can take root.

While everyone agrees that therapy involves emotions, the desire to help, fix and quantify for the sake of financial funding has opened the door to ways of intervention that are too concrete and lack presence and pacing. Higher numbers in shorter time periods get more funding. Like growing 1000 chickens in a space for 100 chickens. Our marketing culture loves numbers. Behavioural interventions try to create measureable change through giving and taking objects and looking at manuals. Over time, it has eroded, distracted and diminished the value of what the parent and therapist brings into the room and created confusion about what effects sustainable change. In short, this article is a call to therapists to leave the manual at home and reclaim the value of skillful presence in the therapeutic relationship.

As the old adage says - Don’t give the client a skill, teach them how to use it. ( Don’t give a man a fish, teach him how to fish.)