Adam Blatner, M.D.

(Revised July 30, 2002)

I think one of the most important processes in psychotherapy is the development of a degree of mutuality in the therapeutic relationship.

By mutuality, I mean that the person being helped actively participates in guiding the helper as to the kind of help that is most helpful!

Mutuality is not the result of good will on the part of the therapist, or even the therapist's openness– although those are essential components. It is a specific process of role training, teaching clients to correct the therapist, and it requires focused intention, explanation, opportunities to practice, to be corrected, to correct in turn, and to become sensitive to the whole process of giving and accepting feedback. It involves a desensitization of the fear that giving feedback to a helper might evoke a negative reaction. Teaching mutuality is what the noted psychoanalyst Franz Alexander called "an emotionally re-educative experience."

In fact, the induction of mutuality in counseling or psychotherapy rarely happens! Further, I would suggest that the lack of this feedback system has been and is a major source of continuing dysfunction in the client's life as well as in the therapeutic process as a factor in "negative transference.". Nor have I seen this process written about.

Mutuality might be thought of as a kind of role training, for the therapist as well as the client. It involves for the helper developing the role of actively seeking feedback, being open and gracious when the feedback occurs. For the client, the role of noticing the helping process and commenting on what seems to be more or less helpful is a form of self-assertion. This role requires the unlearning of subtle or not-so-subtle layers of inhibition and intimidation arising out of earlier experiences–quite pervasive in our culture–in which "helpers" in the form of teachers, parents, ministers, etc. all tended to give their help according to their own view of what kind of help was needed. (Feedback was hardly considered.)

The feedback that is needed in any helping situation includes attention to such themes as:

 * Is the person ready for the next intervention, question, suggestion, challenge... Can a client say, "Wait, I'm not ready for that yet. Can you hold it? I need to... (digest what you said /  think about something else /  tell you something else, etc.)
  Pacing in the helping process is an important variable, and the point I'm getting at is that the helper need not be infinitely sensitive in "knowing" exactly what pace to go at if the client can be empowered to give feedback as to what pace is optimal.

 * Are the words the helper is using really useful? Often certain words tend to have  unfortunate associations, unpleasant meanings-- and these may be idiosyncratic to the client. These words or phrases may seem perfectly kind or helpful to the helper, but in fact they're not-- they're misleading, upsetting, overloading, etc.

 * Are the issues being discussed the issues that the client really wants to address at the time? Often a line of talk will drift away from the client's concerns and follow the thinking of the helper–out of curiosity, following up on a hunch as to what would be helpful to address, or even just some ideas triggered in the helper that it seemed at the time would be helpful to share with the client. However, this is not necessarily true. The therapist remaining silent is not the only alternative to this problem, of course. Clients can be empowered to say to their therapists, "Wait, that's not what I need to talk about now."

It's even possible for the client to not know what other theme needs to be addressed. It would be okay to say, "Not that subject... I'm not even sure what it is, but I want to look for it... there's something else on my mind..."

Illusions of Helping

I will confess to having a bias: I feel I haven't been able to live up to the injunction of my teachers to "be sensitive." Perhaps it is because it's an asymptotic limit–one of those things that you can never completely achieve, and the closer you come to it, the harder it gets. How perfect does one's sensitivity need to be, and when does it cross the line into mind-reading?

So, instead of demanding this of myself, it occurred to me to turn my clients into my teachers and mentors by inviting them to comment on the progress of the therapeutic sessions. I might ask, "Are we addressing the things you want to talk about?" "Are we going too fast? Too slow?" Questions such as these often evoked helpful clues for me, but I also discovered that they had many other benefits, to be mentioned further on.

The point here, though, is to challenge the unspoken demand that therapists should "know" what is going on with their clients. I think this is unrealistic and, indeed, impossible, because people change in their readiness and capacity to learn in the process of learning, or in therapy. (Have you noticed the psychological interplay in learning how to use a new computer program? Have you experienced the give and take of having someone help you? It's a sensitive, dynamic process! There's no way the best teacher in the world could anticipate what I need next!)

A Developmental Model

An example I like to use that illustrates the process of mutuality is that of teaching a child to tie her shoes. It involves many components, and the choice of which type of intervention, and the timing of that intervention, is determined equally by both parent and child. There may be a demonstration on the grown-up's shoe, and then the child can try it on the helper's shoe; or it may be tried on the child's shoe to begin with. Sometimes asking the child which shoe (adult's or child's) should be used for practice grants the child a measure of autonomy, and encouraging choice-making is often an inclusive and rewarding tactic.

As the process continues, there may be occasions when the child says, "No, let me," or "Show me again." There are times for encouragement, and times to be quiet. The parent must be sensitive to the child's readiness, and that includes being open to when the child has had enough for one lesson. Too many helpers push children beyond their level of saturation. The mutual helping process involves a number of gentle questions; the point is that the helper need not be so clever as to "know" what's needed at each step of the procedure. Helpers need not be mind readers. It's better to simply create an atmosphere in which both parties can speak freely about what is wanted next. (This is also true when applied to the problem of psychotherapy.)

Distortions and Dysfunctions

A good deal has appeared lately in the professional literature relating to the importance of "good enough" parenting in the early years. Certainly, insensitivity, neglect, or subtle forms of abuse during infancy can generate in the child a variety of serious personality disorders. Yet even in more normal conditions, children between the ages of four and ten learn to expect frustration rather than success in many of their educational experiences. In the following section we will explore the viscissitudes of what in our culture has been the average expectable "helping" experience. This includes such events as learning basic skills, being comforted when upset, the challenge of dealing with a school situation which is too fast or slow for one's abilities, being bored, etc.

The helper in the early years is not only the parent, but also the teacher, the camp counselor, the Sunday school teacher, the minister, older siblings or other extended family members, etc. The problem, in fact, begins with the helper, because we don't teach helpers how to be flexible, how to individualize the help, and in short, how to be mutual. As people grow into a role in which they must then help others, they are not really prepared. They may know how to do whatever it is they are teaching, but the two skills aren't equivalent.

The typical situation is that of a parent trying to teach a child some skill, or perhaps some good manners. When the child forgets, the temptation is to become impatient, to scold. Part of this impatience is driven by an inner sense of inadequacy in really knowing how to ensure that the child learns the skill. This leads to anxiety and a sense of vulnerability; in turn, many helpers, feeling "too old" for feeling unsure of themselves, become angry. The anger is displaced onto the child, who then becomes perceived as "not trying," "not listening," "not thinking." The culturally reinforced tactic for this situation is scolding, threatening, perhaps even punishing or hitting the child--at least, that's what the parents or other grown-up helpers experienced as children when the educational process went awry.

Notice that what is missing in the helpers' role repertoire is the capacity for mutuality, for relaxing, figuratively stepping back from the impasse, and trying another strategy. Skinner pointed out that effective teaching requires (1) the discovery of the relevant reinforcements, and (2) the breaking down of the task into manageable components. If the learning does not proceed smoothly, re-evaluate and modify these variables.

So, unfortunately, all too often the helping process goes awry, breaking down into scolding, impatience, or dumb submission. Children will often learn what they have to learn, but with less zest. Worse, they become dis-empowered about knowing how to relate mutually. They don't even know that there's anything wrong--they assume that this is just the way the world is.

Eric Berne pointed out four types of interpersonal attitudes: "I'm OK, you're OK"; "I'm OK, you're not OK"; "I'm not OK, you're OK"; and "I'm not OK, you're not OK." The child chooses one of these, based on many factors, including temperament. Some children blame the system, blame the teachers, and from there they go on to rebel in active or passive ways. Other children take it on themselves, assume the teachers must be right, and experience themselves as lazy or dumb. The "not OK" attitudes, whether projected outward or taken inward, lead to later blocks in the capacity to interact mutually.

Further Breakdowns in Mutuality

Problems in this area are exacerbated in adolescence, because most young people don't know how to negotiate for what they want in a clear, non-manipulative fashion. Lacking these skills, they become more devious or, perhaps worse, give in, become compliant, passive, and chronically "dis-empowered". As they try to build relationships with friends, and especially with romantic involvements, the component skills of mutuality are needed to negotiate, to cooperate, to take each other's individual needs and temperament into consideration. Correspondingly, problems in relations between friends and lovers are often attributable to a sheer lack of skill in knowing how to interact consciously and fairly.

With adults, the problems of non-mutuality continue to pervade and contaminate relationships. "He should have known..." "She is so insensitive..." Blaming becomes an easy habit, again one which is so common as to be culturally reinforced. Yet what is missing is the awareness that others should not be expected to read minds, and that each person can seek what they desire, negotiate for it, and make compromises. A good deal of the subtle narcissism that infests our society is fostered by the ubiquity of artificial and unspoken cultural norms which reinforce such residuals of magical thinking.

Again, the principle of "vacuum" behavior should be noted: If an individual doesn't know how to do a given behavior, and if there is some pressure to do something, then a more regressed form of behavior will be enacted and rationalized. Applied to interpersonal relations, if people don't know how to be mutual, then they will engage in alternatives, all of which are subtly self-defeating, such as sulking, blaming or manipulating.

 For example, many (if not most) people have never said to an authority figure, "Will you please reconsider this rule? It's very important that an exception be made this one time." If you imagine what it's like to be an authority, you'll realize that most people in that position enjoy thinking of themselves as flexible, generous, and helpful. If the person asking doesn't have a reputation as a habitual manipulator, chances are you'll grant their request.

 However, the learning about authority figures often occurs in contexts in which those authorities are frequently assailed by manipulations--e.g., the secondary school vice-principal. There may have indeed been rejections, even when the student making the request had what was felt to be the most sincere and justifiable reasons. As a result, all authorities become viewed as rigid and unyielding. Worse, this process of over-generalization occurs unconsciously, and later on in life, the person, then as an adult, doesn't know that he or she is unwilling to "test the waters" by requesting something from an employer or psychotherapist.

Advantages of Mutuality

Teaching mutuality as a corrective experience is, in my opinion, essential as a part of the therapeutic process, in part because it addresses one of the most fundamental and almost inevitable elements in the transference–the sense of mild helplessness in entering a helping relationship in which one doesn't feel one can help the helper be most helpful. But that fear can be addressed and corrected fairly quickly, and I think it speeds up the overall therapeutic process. Here are some other advantages:

An emphasis on mutuality is in harmony with the spirit (if not the actual technique) of some of the advances in psychoanalysis, such as Kohut's emphasis on the importance of the therapist's expression of accurate empathy or Lang's focus on the meaning of patients' verbal content frequently reflecting feelings being held about the therapist and the therapy itself. The approach being advocated here is to highlight this dimension of the interaction itself, because the empowerment of the patient to negotiate with the therapist offers a number of important benefits:

Mutuality also strengthens the patient's ego functions. Learning to assert oneself, establish boundaries, compromise and negotiate--these and other components of a working relationship are exercises for personal growth. This kind of interaction develops the sense of self as locus of control, or as I like to call it, "the choosing self." There is a strengthening of will, of explicit consciousness, and of a capacity for directness in the interpersonal field--qualities which tend to be dilute or deficient in a large percentage of cases.

Third, the difficulty in participating in a truly mutual interaction then becomes an obvious focus for therapeutic attention. Patients come to see in a most concrete fashion that they have difficulty getting what they need in relationships, because they don't know how to negotiate even in the protected context of psychotherapy. This of course is one of the advantages of addressing the transferential distortions in psychotherapy.

Fourth, there is a reinforcement of a more responsible, self-directed, mature style of collaboration rather than a dependent, passive, entitled attitude.

Fifth, the cultivation of mutuality fosters a more realistic, mature appreciation of the therapist, and in a generalized fashion, other people. Object constancy is fostered, which means that meaningful others can be viewed as possessing both strengths and weaknesses, or qualities which are enjoyed along with other qualities which are disliked.

Sixth, the development of mutuality engenders a growing appreciation of the sheer difficulty of communication and collaboration, even when both parties are well- intentioned and capable. Patients are thereby helped to reduce unrealistic expectations, detect and remedy residuals of magical thinking, and recognize the variety of self- deceptions and interpersonal manipulations which can contaminate even the most benign forms of cooperative problem-solving.

Seventh, related to the previous item, patients are helped to learn about such dimensions as differences in temperament or style, the impact of nonverbal communications, and the necessity of interweaving attention to process and attention to content. These are essential skill areas for adaptation to the complexities of the modern world.


Working from this more flexible stance, a therapist can afford to include in any analysis of the therapist-patient interaction the therapist's own capacity for encountering the patient's ongoing needs. This makes the exploration of transferential phenomena more realistic. (It is presumptious to leave out the realities of the subtle difficulties in the therapist-patient interaction and assume that any resistance is due to past experiences with, say, parental or authority figures.)

The treatment alliance can be vastly enhanced and the treatment process intensified when the patient is empowered to function as a collaborator. This is a role they rarely know, and it must be taught to them. To engage mutually with a therapist requires some degree of confrontation of the therapist, some disagreement, some negotiation. Therapists need not accede to every request, but then that interaction should be examined.

For responses, email me.

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