Wednesday, November 25, 2009

Real Therapy vs. In Treatment: The Role of Repetition

Entry for 21 November 2009:

We loved watching the American/Israeli television series, In Treatment, which preoccupied us for two months this past September-October as we patiently watched the 40+ episodes at a rate of 5/week, just as it was intended to be watched. However, one thing that I found a bit disturbing was the fact that the therapy sessions in the TV series appeared to be no more than 20 minutes long, less than half the standard therapy session duration of 50 minutes.

After we finished watching In Treatment we decided to take a look at the real thing, and began working our way through Les Greenberg’s Emotion-Focused Therapy Over Time set of 6 sessions, with additional spoken commentary by Les. After a bit of experimentation we decided that the best way to properly appreciate these is to watch the first 25 minutes of a session, then to go back watch it again with Les’ commentary. In this manner we determined that we could get though a session in two evenings. At this point, we’ve reached the halfway point, having finished session 3 in both versions.

Part of the fun of watching this series is that we know Les, but the fact is, the series is very good: The client, a psychiatric survivor with multiple hospitalizations feels absolutely real, just like the clients that we often see in our clinic settings. She talks at Les, she externalizes, she starts to change then gets ahead of herself, crashes and gets stuck. Les does great work, too good in fact for my students today in EFT-2, who felt de-skilled and intimidated. He also messes up (occasionally) and gets frustrated.

But the thing that struck me when comparing Les’ work (and my work as a therapist also) is the amount of repetition in comparison to In Treatment. That is, there is very little repetition in In Treatment, but there is a lot of repetition in Les’ and my work. When something is stuck we go over it a couple of times, just to see if it will get unstuck; when something new comes out, we repeat it at least twice, and even ask the client to repeat it. Repetition Rules!

It’s easy to see why there is relatively little repetition in In Treatment: The writers were afraid of boring people and wanted to fit a session into a half-hour slot. They were afraid to put too much repetition into the script, because they thought it would rob the program of dramatic vitality. The result is what my grandmother used to call “giving it the fictional treatment.”

In fact, repetition may be an important – but overlooked – aspect of therapy. Once, during the late 1980’s, I was showing Les and Laura a video of my work with a client from the Toledo Depression Project. I complained that I couldn’t understand why my client was still struggling with an issue that we’d already worked over in therapy a couple of times. Les quoted a Gestalt therapy maxim to the effect of, “You have to work through an issue seven times before it sticks.” More generally, it seems to be important that new information be repeated in order to give the client time to let it soak in, that is, to reinforce or consolidate it. Cycling through material repeatedly gives the client more time to process an experience. For example, it is common for new details or connections to emerge when a client with post-traumatic stress difficulties tells their trauma narrative again. Repetition is part of a process of slowing down and dwelling that can be important for helping the client to dig deeper into their experience and to access key emotion schemes and the experiences associated with these.

So repetition can be important in therapy, and is yet another example of a quite broad principle of information science: Redundancy signals importance. In other words, if you want to communicate that something is important, repeat it as many times as it takes to boost its salience to the level desired.

Also, as the Danish theologian Kierkegaard once said, there is no repetition, which means that nothing gets repeated exactly, so you never know when something important is going to jump out, almost by chance, the third time around. And this is an example of another important principle, this one from complexity theory: Self-organizing processes tend to develop by capitalizing on chance, waiting for something new and important to fall out randomly, and then going with it. Complexity scientists think that complex, self-organizing processes, from galaxies to life to brains to cultures, develop in this way. Why not our clients too?

1 comment:

Robert Elliott said...

I'm posting this very interesting comment on behalf of Anja:

Hi Robert
Interesting what you have to say about repetition in therapy in your blog. Certainly something I'm going to be less worried about in my own practice!
It also struck me that this is a very prominent feature in child development and seems to be vital for learning new skills, esp language. I remember playing with one of my nephews who was
discovering object permanence, for hours and hours on end! In autism of course it goes a bit awry and repetition seems to be disconnected somewhat from learning and processing.
Just musing...