Coherence Therapy

Therapy: How To Be Brief When You Were Trained To Be Deep, and Vice Versa, as well as numerous articles and training videos. He has taught widely in graduate courses at JFK University, professional workshop and clinical conferences, and operates a private practice in the San Francisco Bay Area.
This Interview took place in Lisbon, the 20 May 2009, at the International Seminar & Workshop on Coherence Therapy, and to be published.

Bruce Ecker é Psicoterapeuta em Oakland, Califórnia, co-autor da Terapia de Coerência, e co-fundador com S. Bridges e outros do Coherence Psychology Institute. Em Maio 2009 a Sociedade organizou em Lisboa em parceria com o CPI o Seminário Internacional em CT. Esta conversa em torno da TC ocorreu na véspera.

This Interview took place in Lisbon, the 20 May 2009, at the International Seminar & Workshop on Coherence Therapy, and to be published at Psiquilibrios Editions

A.: You come from a family systems training, right?

B.: Partially, but I wouldn’t say that was the main orientation.

A.: Ok, so what would you say are the main influences you can identify in Coherence Therapy either theoretically or as methodological?

B.: We feel we were standing on many different shoulders and so I’ll try to name several. There is Carl Jung’s view of the psyche as coherent, although he may not have used that term, but he saw that any symptom makes sense within the operation of the psyche. The psyche is operating intelligently in producing a symptom. That view is very influential for us. Gregory Bateson, in a very different way yet again an understanding of the coherent production of what is visible—that there are unconscious personal constructs, orderly knowledge structures giving rise to what looks irrational on the surface. Paul Dell wrote about replacing the concept of resistance with the constructivist concept of coherence, and the constructivist brief therapies that were so shaped by Bateson’s ideas, the strategic and systemic therapies, had a big impact on our thinking. The fact that those therapies avoid the underlying emotional material actually got us focused on how to include that material—how to be brief and deep. Gestalt Therapy and other humanistic and existential therapies made it so clear to us that you have to work experientially to get direct access to the underlying, symptom-producing material and make it conscious and create shifts. And there is a mentor who Laurel Hulley and I both fortunately had in our training: Robert Shaw, a therapist who had a strong, clear vision of the possibility of very rapidly restructuring a client’s relationship to a symptom and to the circumstances in which a symptom occurs, creating rapid transformational shifts.

A.: Do you see Coherence Therapy as an integrated system of psychotherapy or more as an eclectic collection of methods?

B.: I see it as a highly integrated system and integrative in that it includes many important features of many other therapies, yet not in a patchwork sort of way. Often the word eclectic is used to mean a loose, ad hoc patchwork that isn’t really unified, whereas Coherence Therapy is highly unified. The conceptual framework and the methods form a very consistent, non-arbitrary overall system of therapy. So it’s truly a synthesis in that it combines many aspects of many therapies into a new whole that isn’t just a loose collection.

A.: How much do you consider yourself a constructivist and also we would like to know if you were already a constructivist while creating this system of therapy and bringing together these various influences.

B.: Yes, we regarded ourselves as constructivists as we were forming Coherence Therapy and defining it to ourselves. We were very interested in the constructivist way of thinking and very impressed by the constructivist approach to helping people alter their experiential reality in a way that would change a symptom. And what we saw was that the constructivist therapies at the time, in the late 1970s and early 1980s, were systems that by design avoided in-depth work with the unconscious. We loved the constructivist way of thinking and yet we also loved and saw great value in-depth work with the unconscious emotional material underlying a given symptom. What we set out to do was to apply constructivist thinking to the unconscious emotional domain.

A.: Still on this topic of how much this system integrates a wide range of therapies, what’s the novelty that Coherence Therapy brings to the field of psychotherapy?

B.: One novelty is what I just mentioned—it’s a constructivist approach to the unconscious emotional world of people, without using interpretation. In fact it’s very important in Coherence Therapy for the therapist not to interpret to the client. And perhaps the main novelty of Coherence Therapy is that it enables a therapist to dispel clinical symptoms through in-depth, transformational shifts, often life-changing shifts, in relatively few sessions.

A.: Right before your eyes.

B.: Right before your eyes, with decisive effectiveness. It’s not a miracle cure, it’s not an easy therapy for some therapists to learn and it’s not a cookie-cutter approach, not just a standard protocol, in that it requires creativity and customization and real sensitivity with each client within a well-defined methodology. It appears to be novel in the field to enable therapists to have that kind of in-depth effectiveness reliably in a small number of sessions. The field assumes that it requires months or years of therapy to have such results.

A.: Which are the most important therapeutic principles that guide your integration? Is it possible to say you had some therapeutic principles that guide your integration?

B.: Yes, I think we can name a few. One is that a true accessing of an unconscious emotional theme and strategy for living is achieved by a fully subjective experiencing of that theme and strategy—a kind of immersive inhabiting or experiencing of that theme as a present emotional experience, as distinct from a cognitive insight about that theme and talking about that theme. A coherence therapist aims in every session to have the client speak from and in the live emotional experience of the relevant material. So that’s one important principle, the principle of accessing by subjectively experiencing the material directly.

A.: Yes, indeed.

B.: Another is a principle of change, and it can be put in different ways, but I like to put it as: People are able to change a position that they experience having, but are not able to change an uncounscious position that they don't know they have. And by “position” I mean a specific strategy for living based in a particular emotional learning or theme. That principle indicates the process of Coherence Therapy, which is to enable someone to first consciously experience the themes and purposes that they are in fact living, that are giving rise to unwanted repeating patterns that we call symptoms or problems. Once these things are consciously experienced, they are then susceptible to a transformational shift.

A.: Ok, great.

B.: There’s another principle for how that shift then happens, and that is also a novelty which is at least as important as the ones I just mentioned. These ingrained emotional themes and purposes and strategies of living that are creating and maintaining a given symptom or problem can be dissolved, and then the symptom ceases immediately. There’s a built-in process in the mind and brain that we identified through studying many profound change events of our clients. What we found is that a transformational shift or even dissolution of these underlying emotional themes occurs when the person is directly experiencing the material and simultaneously experiences another area of direct personal knowledge that is directly contradictory to the knowledge in the symptom requiring material. This is what we call a juxtaposition experience.

A.: This is a novelty too.

B.: That’s a novelty. It has some parallels earlier in the history of the field both in Piaget’s work on accommodation and in Festinger’s work on cognitive dissonance. When we identified the juxtaposition process for deep change of emotional themes, we were surprised to see how it extends Piaget’s and Festinger’s findings to the unconscious emotional world, the world of the unconscious emotional knowledge structures.

A.: Changing the subject a little bit, going to training and supervision. We would like to know how do you conceive it. Which are for you the main steps toward the making of a good coherence therapist?

B.: Well actually there are a number of important components that all work together that a trainee needs to develop skill for. Working experientially is one, a very important one and that is, again, very much about the difference between talking about the emotional themes of the client versus having the client actually drop into the live experience of those emotional themes in the room in the moment. Another important training area is the ability to stay coherence-focused throughout the session, and we mean something very specific by that. Coherence Therapy focuses from start to finish on guiding the client toward and into the direct experience of how a given symptom is actually emotionally necessary to have. So many therapies take a rather opposite strategy of trying to help a person get away from, disconnect from, avoid both the symptom as well as the underlying material generating the symptom and causing all the trouble. Coherence Therapy perhaps counterintuitively heads directly toward and into that underlying material requiring the symptom, and that’s what we mean by coherence-focused. And so, for a therapist to maintain that way of thinking and that way of listening all throughout a session turns out to be a special skill.
Along with that is the skill of communicating what we call coherence empathy to the client. The work needs to be empathic. Empathy can be focused in several different places. The empathy most familiar to therapists is empathy for the experience of having the symptom, the particular distress or hardship that comes in the experience of the symptom. Then there is also empathy for what we call the client’s anti-symptom position, the wish to be rid of the symptom, hatred of the symptom, the client’s wish to be rid of the suffering of having the symptom—that is anti-symptom empathy. Coherence empathy includes those two kinds of empathies, because it’s very important to join with the client’s terrible experience of a symptom and the wish to be rid of it. In addition the coherence therapist again and again expresses coherence empathy, which is empathy for how the symptom is actually very necessary to have, for reasons that emerge very clearly, despite the suffering that truly comes with it. A.: How mature or clinically educated should a coherence therapist be in order to accomplish good sessions? Do you believe we can teach Coherence Therapy to young psychotherapists or do we need more experienced ones?

B.: It’s learnable by therapists at every level of experience including graduate students who have little or no clinical experience yet, and we’ve seen this in various graduate programs. In fact we hear very inexperienced therapists reporting to us words such as “even though I’m fumbling around with Coherence Therapy and really don’t feel I’m doing this smoothly or know how to find my way, even this clumsy application of it is getting remarkable effects”.

A.: You and Laurel Hulley have put a lot of work into writing a Coherence Therapy practice manual and I think you did a very good job, however manuals sometimes have, as you know, the power to keep therapists distracted from clients, because they want to follow the manual and they forget the client, they forget that the map it is not the territory, since Korzybski. They get too focused on techniques and don’t see the bigger picture. How much does Coherence Therapy risk being misunderstood as a constructivist approach by being manualized?

B.: Any system can be misconstrued in all sorts of ways. Coherence Therapy is a fairly complex system and there’s never any guarantee of it being properly understood if someone is trying to learn it only from the manual without guidance. We emphasize when we are teaching Coherence Therapy that it is not defined by specific techniques. It is defined by a methodology, not a set of techniques, and within that methodology it’s open-ended in terms of what techniques can be used to carry out the methodology. We emphasize this and yet we have seen some people take one of the techniques that we teach and use that one technique over and over in a rather mechanical way, thinking this is Coherence Therapy. But therapists who get training in our program are soon guided out of such misunderstandings.

A.: I’d like to come back to your Carl Jung influence and ask you, does a good Coherence Therapy session require a “good client” in the sense of someone with emotional intelligence and able to follow his own emotional experience. And does it require the client to have a clear-cut, functional symptom? In these two ways, how much do you think Coherence Therapy needs special clients with specific problems? What is the applicability of this model?

B.: It’s applicable with a very wide range of people and client populations. It is completely applicable with people who are not self-aware, growth-oriented, or psychologically aware. The therapist guides the client into having experiences. The therapist is free to adjust his or her style and techniques to the individual client and has to come up with ways to apply the methodology with the individual. So two sessions that I do in my office, one after another, can look and feel very different in style and pace and ways of communicating, and yet I’m carrying out the same methodology. With someone who is very self-aware and growth-oriented I’ll work in rather different ways than with someone who is not, and yet both will be guided into the direct experiences of their own underlying material. Everyone is living from their own unconscious themes and purposes—they are right there in the room and we have to know how to get people in touch with these things. There are many ways of doing so.

A.: This leads us to the question of the symptom, the functional symptoms in a Jungian way too. In Coherence Therapy is there the assumption that every problem has its own pro-symptom position? Putting this in another way: do you believe every symptom is always functional? Don’t you believe in “accidentalism” which stands for the hypothesis that diseases are an accidental modification of the health condition?

B.E.: Coherence Therapy does not view all symptoms as functional. It identifies two broad types of symptoms: functional and functionless. Even functionless symptoms are coherent, however, in the following sense. A functionless symptom is a symptom that does not do something of value or get some need met. Every functionless symptom exists as a byproduct, an orderly byproduct of something else that is functional and is needed unconsciously according to some pro-symptom position of the client. The therapist cannot know initially whether the symptom has a function—is doing something needed—or is functionless. There is no way to deduce which type the symptom is, so the coherence therapist does not try to theoretically figure that out. What happens instead is that the experiential process of Coherence Therapy reveals the underlying material giving rise to the symptom and it becomes apparent which type it is, not speculated or theorized.
A simple example is a client whose presenting symptom is an inability to fall asleep—insomnia—and the chronic fatigue this is causing. Then it gets revealed in therapy that all the time, all day long, she maintains either obsessive thinking or compulsive activity, which are needed because if she is quiet and sits still, she starts to feel intolerable feelings and body memory, stemming from what she suffered in being molested as a child. Her obsessive thinking and compulsive activity are functional symptoms that shield her from feeling her unresolved ordeals, and those symptoms in turn cause the byproduct of being unable to sleep, because sleep requires a quieting of the mind, which she must avoid. For her, staying awake and being tired were not meeting some need and had no function in themselves. But for some other client, staying awake could have a function in itself, such as maintaining hypervigilance. It becomes directly apparent from the client’s revealed material whether the symptom is itself carrying out an important function that has great necessity or whether the symptom is a byproduct of something else which in itself has a function and is doing something necessary. What is called “accidentalism” we think corresponds to what we see as functionless symptoms produced as necessary byproducts of functional symptoms that clients might not present or even be aware of.


Part II

A.: Do you see any risk that Coherence Therapy loses its power as a method, as a system of therapy and a methodology as people get familiar or educated in it, or on the contrary? How do you see this?

B.E.: If you are asking whether Coherence Therapy in some way loses its effectiveness because clients become familiar with how it works, no, definitely not. I’ve had many clients who get quite familiar with Coherence Therapy and come back after months or years to work on something else, as well as clients who stay with me, with no gap, and work on some new problem or symptom after the present one is finished. And I see no diminishing of the effectiveness as a result of their familiarity with it. In fact, one of the nice features of Coherence Therapy is that the therapist is free to be quite transparent and revealing to the client about how the therapy works and why the therapist is doing what he or she is doing, if the client has a need to know or to have an explanation.

A.: This would never be unproductive to them. It would never be unproductive for the process to reveal…

B.E.: It’s perfectly ok. It does not weaken the process to reveal it. It can even help, because some clients respond to the counterintuitive quality of Coherence Therapy and say “Hey, wait a minute! You’re bringing me right toward the stuff causing all the trouble, or pain, or distress, or grief, or fear. Why are you doing that?” You know? “Don’t I want to get rid of all this?” Right? Very sensible type of conscious resistance. And what I find to be very reliable for handling that question is to give a short, transparent explanation that this actually turns out to be the most effective way to dispel the stuff causing all the trouble. I’ve said to some clients, “You know, for years you’ve been trying to get away from that material, or to avoid it, or suppress it, or cut it off, or counteract it and it hasn’t worked, has it? And it turns out that it hasn’t worked not because you have failed to counteract well enough, but because counteracting doesn’t work to really solve or transform this stuff. And what does work is to go toward it and get very familiar with it, and then a process of change will open up that will be effective.” And almost without exception clients hear that and are quite satisfied and ready to cooperate.

A.: Would you say Coherence Therapy is totally ineffective with some problems?

B.E.: Well, among client populations at the extreme end of the spectrum of what is often called character disorder (either borderline, narcissistic, schizoid and others) Coherence Therapy may either be ineffective or the work becomes as slow as any other in-depth therapy, because these are people who are so powerfully organized around not accessing their vulnerable, underlying emotional materia—powerfully organized around never, ever opening up to that. And again, all the power is in the client so if the client’s power is that fully against going there, then the client is more powerful than the therapist and the therapist cannot get the client to do Coherence Therapy. There are methods that can be used to foster even such a client to do the wor,k but the work becomes very slow, gradual.

A.: Do you believe Coherence Therapy is possible with children and adolescents, and if yes, what does it require?

B.E.: The answer is yes. It is very nicely effective with children and adolescents. I’ve had that experience myself many times. And what it requires is, once again, the use of ways of communicating that are attuned to that individual child or adolescent. So again it comes down to the therapist’s freedom to adapt or adjust a style of communication, style of interaction and specific techniques that will meet and work with the individual. But yes, I’ve seen powerful transformational effects with children and adolescents.

A.: How much do you believe they are capable of this movement of changing positions from cortical to limbic in a metacognitive way as we adults are able, and children maybe not so much? How do you see this movement that enables the change process, the transformation process?

B.E.: Are you asking about how to understand children and adolescents in Coherence Therapy from the point of view of the brain?

A.: Of the brain and these movements that Coherence Therapy is so skilled to promote. This movement between a cortical view, a limbic view, a cognitive view, an emotional view, the juxtaposition—Hhow much can these shifts and connections happen in an immature brain?

B.E.: And you’re asking about how that happens in children?

A.: Yes. Aren’t children less capable than an adult?

B.E.: On the one hand, in my experience it’s true that adolescents and children are generally less willing, I’m tempted to say. Less inclined, less willing to go into emotional states that are underlying a given pattern or symptom during a session. Whereas with many adults they are willing to revisit a situation, imagine a person, say or do experiential work that gets them in touch with certain emotions that are underneath. And often in working with children and adolescents one encounters a resistance to cooperating with that kind of process. Nevertheless I’ve been consistently able to find ways to engage a child or adolescent in a focus to that same underlying material. A shared recognition that it’s there. I might for example, say to an eight year old girl, “I see, I see you’re really mad at grandma for making the car crash... I see!…”, in such a way that the child feels that I’m not judgmental, it’s safe and it’s ok with me that she’s mad with grandma. The child may not be going directly into the experience of that anger in those moments, and yet there is enough internal accessing of the anger at grandma for Coherence Therapy to happen effectively and for big shifts to happen.

A.: This leads us perhaps to the final topic and theme: Coherence Therapy’s future developments. How would you like to see it being researched besides going under brainimaging, that I know you would love? Coherence Therapy applied to what kind of psychological problems would you like the most being researched, besides procrastination which I understand has been studied?

B.E.: A small pilot study, a initial look at the how to do Coherence Therapy research was done at the University of Florida by Greg Neimeyer and Ken Rice, comparing Coherence Therapy with treatment as usual for procrastination. Very small study that got very interesting results, very encouraging results. So hopefully they’ll do a bigger study where the statistics allow for reliability of the numbers. What’s most important for Coherence Therapy right now is simply a large enough study that shows a strong effect size with statistical reliability and gets Coherence Therapy on the map as an empirically verified therapy, whatever symptom area is chosen. Procrastination is a very good one for that purpose. But what specially interests me, beyond that basic initial need, is research that would examine what we believe may be the ability of Coherence Therapy to have a specific treatment effect. In other words a therapeutic effect that goes significantly beyond the common factors. An effect separate from the therapeutic effects of the common factors.
And here is why we believe that Coherence Therapy may prove to have such an effect. As you know, in Coherence Therapy the client gets directly in touch with a previously unconscious emotional schema, a powerful theme and purpose in which the presenting symptom is actually necessary to have, whether it’s a behavioural symptom or a mood symptom or a thought symptom. What we observe again and again is that this deep new awareness of the underlying necessity for the symptom does not in itself put an end to either the schema or the symptom, no matter how much the common factors are well supplied, session after session. But then, as soon as we create a juxtaposition experience, abruptly the schema dissolves—it loses its emotional realness—and the symptom stops happening. It’s so clear clinically that the specific process that we call juxtaposition has a major therapeutic effect beyond what the common factors alone can do. If I can give you an example it may make the point clearer. A client of mine wanted therapy for the lack of confidence and the self-doubt that he always felt at work. He doubted his own knowledge so much that he felt insecure and anxious, and he usually stopped himself from speaking up and offering his ideas. And yet in fact he did excellent work and had many successful projects under his belt and was well respected by colleagues. So how come he is plagued by self-doubt? Well, we found how come, because that’s what Coherence Therapy does. And what he got in touch with was that his self-doubt is how he makes sure he is not a know-it-all like his father, not an arrogant, dominating, hated know-it-all. In other words, as a child he formed the schema, the emotional knowledge, that to speak with any authority or confidence is being the same as Dad, and he’ll be hated for it like Dad is. That’s an all-or-nothing schema, which children so often form. Well, he made all that conscious, and it felt like a powerful and very meaningful realization, but nothing changed. For weeks it continued to feel true and he kept doubting himself at work. Then an incident happened at work. In a meeting, somebody suggested a key idea that solved a big problem, an idea that my client had just then thought of too, but he had suppressed it as usual. This was upsetting, and he looked around and saw that no one seemed put off—quite the opposite—and then he was annoyed and critical with himself, and nothing really changed. In our next session I used that incident to create a juxtaposition experience, and as often happens, in his responses I could actually see the moments when the old emotional reality lost its realness. After that he no longer felt that speaking with confidence made him the same as Dad or would get him hated for it. His self-doubting simply stopped and he was speaking his ideas comfortably, and this felt like no big deal, he said. It was immediately upon having the juxtaposition experience that it all shifted, even though the common factors were in good supply all along. That’s a very representative sequence that happens consistently with Coherence Therapy clients. We think it’s the juxtaposition experience that creates these profound, lasting shifts that end symptoms permanently.

A.: So you would like to see that specific aspect researched?

B.E.: Yes. We’d like to see rigorous research verify this clinical observation which seems to indicate a treatment effect, namely the transformational effect of what we define as a juxtaposition experience. In other words the big changes that we see as a result of Coherence Therapy observably do not result from the common factors alone. You can give those common factors of empathy, attunement, good working alliance, etcetera, session after session after session and the symptom-requiring emotional schema does not change. It keeps its emotional realness and its grip, and the symptom that it generates keeps happening. All of the sudden finally there’s a juxtaposition experience and it all shifts and releases powerfully. So that’s the clinical indication that Coherence Therapy creates this specific treatment effect that’s beyond what the common factors can do. I would love to see a study identify that in a controlled manner and confirm that. The field has come to believe that the specifics of methodology don’t matter much and that it’s the common factors that create nearly all of the change. We think we have something that goes beyond that. That would be very significant to confirm.

A.: This is not mainstream now, this suggestion you are making.

B.E.: Right. Not at all mainstream. It is quite revolutionary really, relative to the assumptions of the field currently. It’s heretical, in fact, to suggest that a powerful specific treatment effect exists.

(Maybe at the end, but a final question came up )

T.: How do you define a symptom? What’s a symptom?

B.E.: We define the symptom as whatever the client identifies as the experience or situation or repeating pattern that is unwanted and the client wishes it to stop. And to tell you the truth, even though we use the word symptom we wished we had another one-word way to refer to the unwanted, repeating pattern that the client wants to stop, because “symptom” does have a pathologizing connotations and we like the whole system of Coherence Therapy to be free of pathologyzing. It is a non-pathologyzing system so it’s unfortunate that we’re stuck with this word that has pathologizing connotations. And I’ve actually spent many minutes or even hours trying to find a different word and cannot! So if you can help us find one that seems as natural to use, you know, I would appreciate it.

T.: I’ve found that many concepts of Coherence Therapy don’t have the translation to Portuguese. Like “knowings”—we don’t have a word to say it.

B.E.: That’s interesting. Even in English, “knowings” is not in widespread use and sometimes people don’t understand right away what we mean by it. I began using it because it seems to be the word that best describes what’s—its phenomenological—

T.: Because it’s the action of knowing.

B.E.: That’s right. All constructs are used as knowings by the brain and the mind. Knowings of how reality is going to behave. Some therapists just immediately understand and others are quite confused.

T.: I think it’s very like the “structural coupling” of Maturana.

A.: It’s the concept closest to the knowings as Maturana sees it.

B.E.: I think that within the constructivist framework or paradigm, constructivists tend to know what knowings means. Maturana’s framework certainly fits right in to thinking that way. But I think knowings is a natural idea to the constructivist sensibility widely.

A.: Thank you so much!

B.E.: You’re welcome. Thank you.