Chapter 11

THE TACTICS OF THE PSYCHOTHERAPISTS IN SESSION I

As is characteristic of psychotherapy, the men sat back at first and permitted the women to lead off, but they progressively imposed on the relations and subject matter a structure to which the women more or less accommodated. In this chapter, I will describe four tactics which the men used. Then I will compare these to the customary tactics of insight psychotherару in general.

THE TACTIC OF OBTAINING INFORMATION

The first step in classical psychotherapy is to obtain information about the patient. To do this the therapist gets the patient to talk about his problem, then sits back and restrains himself from commenting, except to ask questions and encourage the patient to go on.

A typical demeanor is used in this stage of psychotherapy. In strict applications the body is held immobile, and the face is set in an impassive, deadpan expression. This kind of expressive control is believed to minimize cues which may influence the patient’s selection of topics and viewpoints.

In addition a psychotherapist keeps his distance at the beginning of a course of sessions. He can converge his eyes at a point beyond the speaker and overproject his voice so as to speak to the room at large. He can avoid tête-à-tête relations and keep physically beyond the usual distance for rapport. And he may maintain formal paralinguistic tones. Whitaker and Malone began Session I with these classical behaviors.

Influence from the Position, Listening

A therapist can exercise a great deal of influence from this position. He can reinforce or discourage certain topics by the use of minimal kinesic cues. He can interdict certain violations and thus maintain the definition of the situation. He can maintain the distance or else decrease it and foster rapport. When there are family members or multiple patients he can subtly foster a relationship with one of them and discourage rapport with the other. Such maneuvers in the tactic of listening direct the subsequent behavior of the patients and set up the more specific definition of the transaction. And the appearance of such weighting in the early behavior of the therapist previews his later technique.

Whitaker and Malone seemed to influence the topics and behaviors of the women by the use of such maneuvers from the first minute of Session I. Thus I called their position seiective attending. The maneuvers they used were (1) influencing the topic, and (2) monitoring certain behavior:

1. Influencing fthe topic. On three occasions Malone asked Mrs. V to talk about the day Marge became psychotic. But Whitaker questioned her, at Marge’s instigation, about her own illnesses and about earlier events in the V family history. Thus the two themes of Session I were in part chosen by the men.

In a similar way, Whitaker screened what Marge had to say. He selectively attended her when she spoke about problems in the family and ignored her other comments. And Malone made it clear that the did not want Marge to talk about her sexual behavior and ‘her sin’ at this point in the session.

2. Monitoring Certain Behavior. Since the therapist is generally impassive, the few cues he does furnish may be doubly influential. Certain kinesic monitors, not recognized in common culture, have escaped the censorship of psychiatric self-discipline. Three examples are nose-wiping, looking away, and lintpicking (see Chapter 5). It is usual in psychotherapy to see psychotherapists pick lint from their clothing or wipe their noses, despite their dead pan expression, when the patient acts in ways or speaks about behaviors which are not socially approved. When we see which behavior of the patient elicits these monitors we can sometimes predict the areas which the therapist will later choose for confrontation and correction.

Thus in Session I Malone wiped his nose at Marge’s sexy behavior and Whitaker picked lint and looked away. The men also picked lint and frowned when Mrs. V denied and rationalized.

Selective Attention to Marge

As the reader knows Whitaker overtly supported Marge and encouraged an alliance with her. He did not do this with Mrs. V, and Malone, who overtly supported Mrs. V and scolded Marge, contributed to the rapport formation with Marge by his covert behavior. Thus rapport with Marge was selectively escalated, while the initial distancing was maintained with Mrs. V. This was appropriate since the men were going to dismiss the mother from further participation. Here are some of the maneuvers by which this was done.

1. Whitaker’s selective support. Whitaker picked up Marge's comments and sharply questioned Mrs. V about them. He also moved in toward Marge. And he developed an informal style with Marge which he did not extend to Mrs. V.

2. Malone's ironic support of Mrs. V. Malone said the words which would support Mrs. V's arguments, but remained formal with her and tended to load his comments with innuendo which suggested a failure to accept the woman’s allegations. At times these loaded comments amounted to subtle confrontations of Mrs. V’s position, so I will describe them more fully below.

3. Malone's kinesic attentions to Marge. Finally, Malone scolded Marge but he moved in synchrony with her for the first five minutes of the session and again from 2 3 minutes on.

Numerous instances of this behavior are depicted in the multimodality transcript in Section B. Malone moved his leg exactly as Marge had done at 28 seconds. From 1 minute: 30 seconds on, Malone and Marge both made stroking movements with their hands — Marge on her leg, Malone on his chair. These were carried out in perfect synchrony and lasted nearly a minute. At 4 minutes and 52 seconds Marge took out a Kleenex and blew her nose. Immediately afterward Malone took out a handkerchief and did the same thing in the same rate and rhythm of movement.

As I stated in Chapter 7, such synchronous behavior is an indication of a developing relationship which later will become manifest.

In summary we can say that the men began the session in the classical manner. They listened and questioned, maintained psychotherapist impassivity, and at first avoided any instructions. But their later tactics were presaged by their initial kinesic behavior as invariably it is in a transaction.

THE TACTIC OF FOSTERING RAPPORT

As Session I proceeded Whitaker escalated his selective attention to Marge into a developing relationship of the type which psychotherapists call rapport.

Characteristics of the Rapport Relationship

In Phase I rapport existed temporarily. It was formed late in a Period 1 and dissolved at the end of each Period 2. In Phase II it became lasting and persisted throughout subsequent sessions.

At each formation of rapport the following sequence would occur: Marge and Whitaker would address each other in a t՛ête-×tête and converse briefly. Then Marge would shift to sitting like Whitaker and would confront her mother.

Thus the rapport relationship was a temporary vis-a-vis which was used as a transitional step to a side-by-side alliance. It was thus open to interaction with other people. It was not closed by cross-monitoring, for instance, as was the mother-daughter relationship. Marge used the relationship to argue with her mother. In Phase II and subsequent sessions she used it to relate to Malone, perhaps to learn flirting, tactile contact, and other nonsexual behavior s under Whitaker’s protective aegis.

Thus the rapport relationship is not a sexual relationship per se. It is also not a closed dyad in the sense that a marriage or a parent-child relationship may be in traditional cultures. If rapport does become a closed dyad it ceases to serve its tactical and strategic purposes and becomes an end in itself. Like other dyads it is supposed to be temporary.¹

The Progressive Moving-In Series

I have already described the pacing by which Whitaker moved forward every six minutes, and I have described how he stepped up his proximity and support of Marge at each step (see Chapters 1, 6 and 7).

Maneuvers in the Fostering of Rapport

Schizophrenic patients are notoriously fearful of new relationships and premature, tactless attempts to induce such relationships may result in an increased autism and distrust from the patient. It may also result in intervention by family members. In Session I Mrs. V monitored Whitaker’s and Marge’s approaches to each other and Marge did pull back and repel Whitaker. So part of the psychotherapist’s communicative skills involve his judicious use of the tactic of rapport inducement.

We already know that Whitaker moved forward in steps. Here are some other maneuvers and tactical modifications that he used in Session I.

1. Whitaker moved in when he received an invitation from Marge and not at other times. Participants may indicate their readiness for an address and thus invite a relationship by using kinesic behaviors. Marge used them all. She would trail off in her contention with her mother and drift away from the older woman. Correspondingly she would lean toward Whitaker, uncross her arms, and turn toward him. She would search his face with her gaze and show hesitance or uncertainty in her behavior. At 6 minutes she lamented and quasi-courted. At 10 minutes she dropped her handkerchief near him.

Whitaker moved in when Marge made this appeal.² She did make appeals at other times which Whitaker passed up. The safest interpretation is to say that Whitaker selected Marge's appeals at six minute intervals to conform with the pacing of the session.

2. Whitaker did not court Marge. Whitaker engaged in tetea-tete and contacting behaviors with Marge but he did not act seductively toward her. I have elsewhere described such behavior as quasi-courting (Scheflen 1965). It is used by psychotherapists in general. This pattern is not seductive in middle-class America.³

3. Whitaker avoided the persistent exclusion of Mrs. V from his relation to Marge. A full body vis-à-vis excludes third parties from participation. Whitaker and Marge avoided a full vis-à-vis. In the first tactile contact, for instance, Whitaker looked and talked to Mrs. V. He did not even look at Marge when he handed her the Kleenex. In the second, Whitaker turned only his face to Marge.

Thus by relating to Mrs. V lexically and to Marge kinesically, Whitaker maintained the multiple simultaneous relations I described in Chapter 7. We can hold that such a procedure is necessary in any transaction which involves more than two people. But in Session I special tactical considerations were involved. We can guess that a persistent Whitaker-Marge twosome would have brought intervention from Mrs. V and Malone, and Marge might have returned to huddling against mother. Insofar as Whitaker and Malone encouraged multiple simultaneous relations, then, they were acting tactically to encourage rapport.

4. Whitaker did not try to hang on to rapport with Marge when she broke off to return to her mother. When Marge would break off with Whitaker and return to sitting with her mother, Whitaker would also turn away from her.

It seemed that Marge exhibited dissociation from Whitaker to conform to the plans for maintaining the mother-daughter interlock. Maybe Whitaker shared in this behavior for tactical reasons.

The Tactic of Metacommunicative Discrediting

A basic technique of the expressive or insight psychotherapies consists of the use of metacommunicative behavior to discredit certain metaconceptions of the patient which are adjudged unrealistic.

In Session I such tactics were employed gingerly toward Mrs. V's story. In later sessions they were directed to some of Marge’s ideas.

In Session I Whitaker more overtly used the metacommunicative tactic, but Malone participated subtly.

Subtle Metacommunicative Qualities in Whitaker' s Attending

Whitaker used subtle kinesic behavior in attending and questioning. He would ‘suggest* through facial expression that Mrs. V question her own story.

One kinesic technique for doing this is in general usage. When someone makes a dubious statement, it can be questioned by assuming a dead pan expression, staring at him, and withholding any signals of approbation or comprehension. Whitaker did this whenever Mrs. V used denial or rationalization.

There are other kinesic metabehaviors or gestures which make a discrediting or questioning comment more directly. A shrugging of the shoulders is one of these. Raising eyebrows and holding these while slightly cocking the head is another. Whitaker used these subtler indications of dubiety, rather than the gross discrediting kinesics which Marge employed.

Selective listening steers the direction of a speaker's topic. One can act bored when he takes certain directions and interested when he takes others. Thus a therapist can make notes when a patient discusses certain topics or nod his head and attend closely. Then, with other subjects he looks away, doodles on his note pad, yawns, and so forth. Thus the patient can be conditioned to operate along certain lines of behavior. Whitaker used a variant of these maneuvers of selective attention. He would glance at Marge when Mrs. V related certain incidents and get more involved in kinesic representational behavior with the girl.

The systematic use of all of these maneuvers can alter a definition of the situation. Searching glances to others, signaled inattention to the speaker, the withholding of comprehension and approval, and indications of boredom can turn off a speaker and invite someone else to interrupt him.

Whitaker and Marge allied to interrupt Mrs. V. They did so by escalating such subtle indicators. Ultimately there would be a gross interruption of Mrs. V by one of them. It is usually this way in an interaction. Covert kinesic behaviors develop progressively until one party finally performs an obvious act. The practice of assigning an originator can thus be misleading. We erroneously blame the person who took the first obvious step in the reciprocal sequence. We may realize the difficulty when we try to decide who initiated a fight among siblings or who started a lovers’ quarrel.⁴

Malone's Use of Metacommunicative Innuendo

The innuedo is an instance of metacommunicative manipulation. A participant qualifies his behavior in such a way as to suggest another possibility. Malone often did this in Session I.

At one point when Mrs. V was under fire because of an insinuation that she had neglected her baby, Malone supported her ironically. What Malone said was, ‘You would do anything for her,’ allegedly affirming that Mrs. V would not have been guilty of neglect. But his paralanguage and stress pattern conveyed a different implication. He placed so strong a primary stress on ‘anything’ and so retracted a drawl on the word that a sharp incongruity was evident. This configuration usually serves to exaggerate a comment of praise to render it plausible.

Malone also used innuendo as a confrontation early in the session (see page 3 of the transcript at 2 minutes and 1 second). He asked Mrs. V, ‘Where is your husband?’ The husband had not been previously mentioned during the session, so the usual structure would call for the primary stress to be placed on the ‘where’ or on ‘hus(band)’. ‘Malone put the primary on ‘is’ — a structure used when the person in question is then under discus sion. He thus acted as though they had been talking about the husband all along.

This usage makes no sense except in a very special context. Marge had been talking about getting sexy. Malone thought she was unwittingly referring to her father and subtly made a connection. This is a technique sometimes used in psychotherapy to suggest an interpretation to a patient by innuendo, such that the patient can pick up the connection if it is not too disturbing.

Malone is generally aware of such behavior, using it as a covert, but purposive, technique of psychotherapy. I think he used innuendo to make subtle confrontations and qualify his overt role of supporting Mrs. V. This behavior, coupled with his kinesic relation with Marge, presaged and fostered both the withdrawal of Mrs. V and the rapport between Marge and Whitaker.

Metaconceptual Connecting: The Special Use of Confrontation by Whitaker and Malone

Whitaker and Malone do not believe that it is necessary that the patient have a systematic and fully conscious picture of his discrepant conceptions. They believe that the necessary ideational connections can be made out of awareness. In fact they believe that the schizophrenic patient's misconceptions are preverbal and are not even coded in the conceptual systems which are derived from language.

Accordingly their techniques for changing metaconceptions are not aimed at conscious linguistic expression. They do not require that the patient be able to talk about his insights. In fact they prefer that he not do so and they do not interpret in the classical psychoanalytical sense. In a sense they see their efforts directed at helping the patient make connections of some sort between experience in the immediate relationships and his symbolic representations of experience.⁵ They use at least the following maneuvers to this end.

1. They call attention to a connection between ideas they believe are related by restatements which link the ideas together in a single syntax. For example, late in the session Mrs. V was talking about her family home in childhood, her present home, and her expectation that Marge would return there. Marge was talking about going to hell. In this context Malone said ‘You mean hell?’ And Whitaker detailed this reference by saying: ‘You mean hell is her home? Kinda like it was yours, huh?’

2. If the therapists have a thought which seems to refer to the patient's problem, they will state this thought even though they cannot formulate its connection explicitly. Thus they may tell the patient a fantasy or affective response they have had, much as a patient is expected to do in a classical insight therapy. They may then discuss this idea with the patient, bfut they believe a connection may be made whether or not the matter is discussed. For example, in Session IX Whitaker told Marge that he visualized her with a hole in her head. It was not clear what this imagery referred to.

3. They may simply respond to representational behaviors of the patient with other representational behaviors without explaining or being able to explain the significance. For example, Whitaker made tactile contact with Marge.

The smelling incident is interesting in this regard. ‘Why,’ the researchers asked, ‘did Whitaker have Marge smell the object in his hand?’ As he did so, he said the object was Parmesan cheese. Whitaker intercalated this behavior in the middle of an explanation of the sessions which would end with Mrs. V's dismissal from future sessions. My own guess is this: Whitaker used a representational behavior whose reference was Mrs. V. Mrs. V was the Parmesan cheese, and Whitaker was attempting to convey his metacommunicative attitude about the quality of her mothering.

Whitaker thinks this may be so but is not sure why he did it. He said it intuitively seemed the correct maneuver to follow. Such refusal to explain each action characterizes the men’s metabehavior about their method. When they teach it, they often comment that they have no explanation. In part this lack of explicit rationale is a result of their application of a maneuver even when they cannot explain it. In part, I think it is a purposive opposition to the classical insight therapist who insists upon a conscious rationale before acting. Whitaker and Malone feel this is poor practice because therapists who act on this injunction may fabricate complicated rationalizations for their behavior in therару and eventually set an example for the patient who gets lost in ‘intellectual’ rumination.

THE TACTIC OF EXPLAINING

During the first twenty-three minutes of the session Whitaker had progressively moved forward into the position of principal narrator. At this point he took the floor and explained the purposes and plans for the sessions. In doing so he carried out two actions. First, at 24 minutes, in the middle of the explanation, he placed his palm under Marge’s nose and asked her to smell the object he held there. The second or 24 minute physical contact was made.

I have described this action before, but a drawing is reproduced as Figure 11-1 to refresh the reader’s memory.

Then, Whitaker went on with the explanation. As he described the plans for future sessions he made it clear that Mrs. V was not to attend them.

Whitaker’s explanation and his dismissal of Mrs. V completed the progressive engagement of Marge in the session. She was brought into the prominent role that Mrs. V had occupied. Malone then engaged her actively in vis-à-vis and Whitaker became relatively quiet. This Phase II structure was maintained throughout the other eight sessions of the series; Malone became the active therapist with Marge, while Whitaker assumed the less active position of intermittent intervention that Malone held before 24 minutes״ So the 23-24 minute intervention was a critical turning point in the course of this session and of the series of psychotherapy sessions.⁶

Figure 11-1:Whitaker’s Position at 24 Minutes for Explaining and Tactile Contacting

COMMENT: CUSTOMARY AND UNCUSTOMARY FEATURES OF THE WHITAKER AND MALONE TECHNIQUE

The Whitaker and Malone approach is to be classified with the expressive or insight therapies. In classical psychiatric terms, feelings and thoughts (misconceptions in metasystems) result in behavior that is inappropriate to reality (to the actual life contexts). Accordingly, the strategy of an insight therapy calls for the patient to become aware of his behavior and his conceptions in order for these to be altered.

The Usualness of Their T actics

The following interdependent tactics are used in any expressive or insight therapy:

1. Tactics for learning about the patient’s behavior and conceptions, followed by: Tactics for encouraging the patient to learn about his behavior and metabehavior, and

2. Tactics for fostering and regulating the rapport relationship.

Whitaker employed these techniques in Session I and Malone did in subsequent sessions. It is also characteristic in initial interviews to explain the purpose and plans of psychotherapy. So the four tactics which Whitaker used are customary in psychotherapy.

The men also used the basic demeanors of psychotherapy — the restraints of facial expression and movement which tend to minimize metacommunicative instruction to the patient.

Figure 11-2 shows some features of tactical progression in another psychiatric interview. In this particular session the following phases occurred.

Figure 11-2:Regularities in Another Psychotherapy Session. Above, In this psychotherapy session the patient would drink from a glass of water and make a reference to his father. The psychotherapist would then make an interpretation about his dependency. Below, This complex occurred every fifteen minutes in two sessions. The structure is analogous to that of the tactile contacting in Session I. The therapists would ‘use his technique’ at 15 and at 30 minutes in response to a characteristic representational behavior of the patient.

The therapist listened as the family members recounted experiences. He did not move in very much, but he did escalate his participation after the seventh minute. At fifteen minutes the patient took a drink of water and mentioned his father. Then the therapists interpreted the patient’s dependency on his mother. Immediately afterwards the patient and therapist shifted posture and returned to their original positions. In the next fifteen minutes this sequence was repeated. And in the second session the same format was used.

A format like this appeared in all but two of the psychotherару sessions I have studied. Some of its features are illustrated in Figure 11-2.

Figure 11-3:Types of Progressions in Therapists’ Positions. [Reprinted from Psychiatry]

The diagram in Figure 11-3 represents the timing of steps in customary program of progression.

The implication of this finding is clear. Though this progression is not explicitly taught in psychotherapy, it must be learned in the preceptor system of teaching psychotherapy by identication, or else it has a prototype in many such transactions in the culture. In any event the procedure is institutionalized and Session I is a replicate of a basic transactional form that is in widespread use. In other words, though the participants may have modified the procedure and given it their own style, they did not invent it for the occasion. They must have held some similar cognitive image and plan for the units of behavior (Miller, Galanter, and Pribram I960), brought it to the session, and enacted it.

Other features of Session I might not usually appear in the psychotherapy of the neurotic patient, but they are often employed with schizophrenic patients. The moving-in series is not usually pronounced in the therapy of neurotic patients. The therapist will move only slightly toward the patient. And the use of tactile contact was unusual in the 1950s except in the treatment of the psychotic patient. By and large, psychotherapists feel that more intense and heroic measures are necessary to gain rapport with the schizophrenic patients.

Comparison with Other Sessions of Family Therapy

The Whitaker-Malone series was in one way usual for family therapy. Family therapists and group therapists tend to alternately support one group member after the other in presenting his case — a technique Whitaker and Malone did by taking sides complementarily. In family therapy it would not be usual to dismiss the mother after two sessions. Some therapists use this approach, but it is more characteristic of the previous tradition of family interviewing in child psychiatry. In some measure Whitaker and Malone’s dismissal of Mrs. V was influenced by the research team who had invited them to Philadelphia to demonstrate individual therapy.

In making these comparisons it is important to bear in mind that Whitaker and Malone have been pioneers in developing these methods of therapy for schizophrenic patients and for the family. Many of the strategies that were relatively unique in 19 59 have now been widely adopted.

So the program of psychotherapy has come to be institutionalized. Particular arrangements are made for it, therapists and patients both have come to know the rules, and the timing has been pre-established. Thus an interview takes thirty to fifty minutes, a series of sessions are planned for, and certain strategies are phased in and out in a course of multiple sessions.

As I have described, Whitaker and Malone used special variants of confrontation. They also tend to speed up the rapportmaking procedures and add tactility and representational exchanges.

The Structure of Session I as Compared to That of Other Psychotherapy Sessions

The tactics of psychotherapy are programmed. They are applied in steps in an over-all strategy.

The psychotherapy session ordinarily consists of a series of phases. There is an introductory period for taking seats and arranging the initial positions and orientations. In this phase the participants usually preview the patterns of behavior they will employ — as they did in Session I. Then they settle back for a first phase of narration and presentation. The patient recounts his difficulties or history, and the therapist attends the account. After ten to fifteen minutes, most therapists move forward to initiate raooort and step up their questions and comments. Then, when rapport has been established, the therapist makes the more active intervention which characterizes the technique of his approach reassuring, confronting, interpreting, making physical contact, etc. Then these three phases are repeated and the session is then terminated.

The second cycle tends to vary in several ways. The patient is encouraged to associate his current life behavior (which he described in the first sequence) to past experiences. The therapist-patient closeness and rapport are likely to be deepened or intensified, and the second intervention will be more comprehensive than the first.