The Use of Strategy in Clinical Work, Part I

According to standard therapeutic principles, deliberate strategizing should be out of the therapeutic picture. As a therapist you don’t know what the patient is really thinking. Certainly your hopes and fears for the patient, traditionally known as transference and counter-transference, are to be contained. The patient ultimately provides the direction for the work, not you.

Reasonable? Indeed. As a corollary, therapists and physicians know not to treat their friends or family members because in those situations therapist needs invariably contaminate the clinical field.

So, what if anything is wrong with a strategic-less psychotherapy?

Think back to Ken from an earlier newsletter. He was a pessimistic teenager who believed he had to finagle his way through life. He couldn’t imagine making his needs or personal attributes known to his teachers or parents. Ultimately discouraged, his grade point average in school just kept deteriorating.

Oh well, if Ken looked like a druggie and preferred fringe friends, he probably was a druggie. Ken’s parents believed that and even Steve was being taken in, at least until a copy of The Economist slipped out from the sleeve of Ken’s hooded sweatshirt. More striking, Ken had read and mastered every article in that and most of the other recent issues.

From that point, I (Steve Frankel) swung into action. I understood some of the psychology of Ken’s self defeating behavior. Undoubtedly it might have been helpful for me to help Ken focus on this issue. But, would that be enough, and how do you talk psychology to someone who doesn’t care to listen, anyway? I needed a strategy to get Ken to care and believe that if he and I worked together his lot might improve. The strategy had to include enlisting Ken’s furious parents to again believe in and support him. I needed to find a game plan that Ken’s parents and I, and Ken and I, at first separately and then together, believed in. My strategy, as I formulated it, included cognitive testing for the purpose of confronting Ken and others who knew him with his obviously superior intellect. There was also the task of regulating myself when I became so enthusiastic about Ken’s potential that my passion and no longer Ken’s might provide most of the fuel for treatment.

But, the bottom line was that Ken, his parents, and I had a job to do. Thinking and talking were simply not enough. We had to do more. We required action. I warrant that if we had decided that therapeutic strategizing was a corruption of proper technique Ken might still have his sweatshirt over his head.

Were there other ways for me to skin this cat? Much of the contemporary research on psychotherapy, how it works and how to do it, defaults to cognitive behavioral techniques. Using this approach, I could have focused on changing both Ken and his parents’ misapprehensions. Good idea, but think again. Telling Ken that he should crow about his IQ and recognize how easy it would be for him to get “straight As” had been tried many times and failed. More than corrective instruction was required to dent Ken’s assumptions.

The point is that strategy is complex. At minimum it requires cognitive, affective, and surrounding these, cultural considerations. Ken, even when he found out how smart he was, was devoid of techniques for planning. He also connected enthusiasm with the constant disappointment and criticism he experienced when he’d had those feelings in the past. In his case, strategy also had to include instruction in organization and planning, and gentle, on the spot, handling when trying to succeed in school signaled to him that an attack was close at hand.

Our position is that being strategic does not require you to violate principles of boundary maintenance or any other cardinal rules of therapeutic decorum. In fact, we would be hard pressed to think of a productive therapeutic situation in psychotherapy, psychiatry, or even medicine where interpersonal strategizing isn’t somehow part of the equation. Therapists need to have the patient’s attention and commitment, physicians should be sure their patient is taking the medication they prescribe. In Ken’s case, Steve needed a receptive client for any work to get done. The caveat is that strategizing be focused on the client’s welfare, devoid of the clinician’s self-interest including his or her need for admiration, and be done collaboratively, not manipulatively.

In this newsletter, we’ve only broached the subject of strategy in clinical work. Developing a clinical strategy often requires thinking outside of the box, going beyond clinical conventionality. Most therapists do this as they need to. But, how regularly are we deliberate about our strategies? How much effort do we put into justifying the strategy we choose, and how assiduously do we apply ourselves to revising our strategies as the clinical requirements in a case change?