John Marzillier’s autobiographical account attempts to convey what the experience of therapy ‘is really like’. Rather than elucidating case histories, he has provided a fictionalised, novelistic memoir of cases spanning his four decade career. Marzillier began working as a behaviourist and became during practice a cognitive therapist, and finally a ‘psychodynamic narrative therapist’. The book’s title relates to the uniqueness and importance of the ‘real relationship’ (Duqette, 1993) between therapist and client.
The Gossamer Thread provides an insight into the experience of therapy for the psychotherapist. It does so without any attempt at objectivity or summation, rather it represents the particular and unique experience of one practitioner, deeply rooted in his own autobiography.
The author points out the liability and unreliability of his (and his clients) memory of events, arguing that this no obstacle to understanding the uniqueness of individual perspective. Perspective, the way in which we view our histories and positions in the world, is open to change, and it is this change Marzillier suggests is key in psychotherapy (Marzillier, 2010, pp8). Marzillier emphasises the contiguity between normality and disorder – the continuum along which anxiety and depression run, laid down by social norms and expert discourses. Marzillier himself utilised ‘electrical aversion therapy’ with gay clients (in the 1960’s). His experience as an influential participant in a rapidly changing discipline (clinical psychology), made him keenly aware of ambiguity and ethnocentricity of diagnosis and mental illness.
By ironically reflecting on his own imagined competence as a new behaviourist practitioner, Marzillier demonstrates the man behind the curtain of psychotherapy (Marzillier, 2010, pp29). This is especially pertinent given the popularity of behavioural approaches in the treatment of autistic spectrum disorders (Rosenwasser & Axelrod, 2001), and cognitive behavioural approaches to depression (Leichsenring, 2001) today.
It is noteworthy how much more of himself Marzillier required as a practitioner of psychoanalysis, and how much more emotionally challenging the process seemed (Marzillier, 2010, pp169). Marzillier also notes the higher requirements on the client in psychoanalysis, the ability to tolerate the pain of unconscious exploration, reflexivity, commitment to long term treatment, trust in the practitioner (Marzillier, 2010, pp135).
Too often in accounts of psychodynamic work, the duration disappears, the months of work without progress becomes dissolved by the relatively brief narrative description of the case. Marzillier bucks this trend, demonstrating the slow progress of re-parenting a closeted narcissistic client. Here he introduces an interesting concept from self psychology (Kohut, 2009) (a sect of psychoanalysis that seems to mirror object relations with different terminology) – ‘Selfobjects’, external ‘objects’ that the narcissist cannot separate from their internal function or perceive as separate to themselves, a defense against unbearable emptiness / disillusion (Marzillier, 2010, pp177).
Marzillier argues for the utility of brief psychodynamic therapy (Marzillier, 2010, pp200) – as a means of rapidly approaching insight for the prolonged grief of his patient (rather than the relief of suffering, as in CBT).
Having been educated right when ethology / behaviourism was being superseded by the cognitive revolution in psychology (Marzillier, 2010, pp69), and at a time when psychoanalysis was gaining popularity in Britain (despite its dismissal within academic psychology), Marzillier is in a unique position to highlight the arbitrary way in which intellectual fashions choose to focus on specific aspects of personality or cognitive function. This parallel’s my own experience, studying psychology at a time when cognitive science is being integrated (somewhat tortuously) with neuroimaging.
Marzillier argues for the need to shape psychotherapy to the individual client, and to continually critically evaluate the assumptions behind theory and practice and the origin and meaning of client distress. He also demonstrates the importance of relationship over methodology in addressing the needs of clients (which can vary significantly from their presenting problem) (Marzillier, 2010, pp24). I share Marzillier’s dislike of the value laden conception of personality disorder (and psychological disorder in general), rooted in a syndromal disease model that lack construct validity (Clark et al, 1997). I found Marzillier’s reference to the work of Jerome Frank on the ritual of psychotherapy (as more important than the technique / theory) fascinating, as it relates to Erving Goffman’s theories on the dramaturgical aspects of everyday life (Marzillier, 2010, pp25).
Despite his later disavowal of behaviourist treatment approaches, Marzillier describes a number of successes in treating phobias, anxiety disorders and the like with behavioural approaches (Marzillier, 2010, pp32), and later similar success with social phobias, teaching social skills with feedback (Marzillier, 2010, pp52). Given the irresolute nature of outcomes in psychodynamic psychotherapy, it’s hard not to find this attractive. Similarly, last year I studied ‘choice theory’ (Glasser, 1998), a cognitive approach to behavioural change rooted in needs and contemporary relationships; and I find it challenging not to apply any of these techniques to client work. However, as Marzillier goes on to demonstrate, clients differ enormously, and simple techniques are not necessarily universally applicable (Marzillier, 2010, pp44, pp57). Focusing too intently on specific symptoms or (frequently misapplied) diagnosis can professionalise the clients identified disorder (Marzillier, 2010, pp47), providing a (toxic) identity as well as a sense of learned helplessness. Marzillier argues for a therapeutic approach rooted in aspects of a variety of techniques – the anxiety / depression reduction of cognitive therapy, the use of transference and the working alliance of psychodynamic therapy (Marzillier, 2010, pp188)
Another issue which arose for Marzillier was his client’s reluctance to take ‘trained’ learning into the real world (Marzillier, 2010, pp60). This is an issue I’ve found myself as a client of therapy – it’s a great deal easier to come to an insight than to apply it in practice. There are several important take home messages here: One, for behavioural therapies to work they need to be as ecologically valid as possible, even taking place in the real world. Two, a great number of client’s core issues are disguised by their surface problems. Three, as I discovered during the course of my own undergraduate thesis, experimental power requires large, homogenous groups of participants (Marzillier, 2010, pp61).
Although Marzillier later disavowed simple behaviourism (Marzillier, 2010, pp75), his practical approach to the difficulties of clients – informed by cognitive and behavioural accounts – is appealing. For example with one client ‘Angie’, his focus on cognitive factors (‘vicarious traumatization’) helps to elucidate the origin of violent fantasies and ultimately remove their severity (through self monitoring and curtailing avoidance) (Marzillier, 2010, pp78). He’s never averse to trying to help a client resolve their difficulties, rather than to simply accept them or endlessly ruminate upon their origins.
I found a number of Marzillier’s reflections on the psychotherapeutic process enormously insightful; ‘avoidance prevents… anxiety from going away’ (Marzillier, 2010, pp77), ‘significant change always entails a significant loss’, (Marzillier, 2010, pp92), aggression can be expressed through gratitude (Marzillier, 2010, pp156), passionate love is ‘the archetypal narcissistic illusion’ – the projection of what’s missing in oneself into the other person (Marzillier, 2010, pp260), cognitive appraisal (negative thinking) affects how you feel (Marzillier, 2010, pp93) and negative feelings that persist become depressed mood. Never having studied CBT, I found the detailed description of a variety of cognitive distortions and schema underlying depression informative.
For Marzillier, work with a variety of clients demonstrated that core beliefs (schemas / metaphysical beliefs) were difficult to mollify with cognitive techniques (Marzillier, 2010, pp111), and more amenable to emotional challenge from within, from a place of safety in therapy. There’s an intrinsic issue with any kind of cognitive therapy – and it is that the most useful, cheering belief may not be true, and whether true or untrue may not be good for the individual to hold, or the community to be subjected to (as for example in the destructive behaviour of narcissists). Marzillier’s own issues with cognitive therapy arose as much out a disillusioning of his idealisation of his mentor, Aaron Beck, during an embarrassing tennis game, as through rigorous methodological critique (Marzillier, 2010, pp 127)! Problem solving is useful in some circumstances, the important thing is to tailor the treatment to the client’s needs (Marzillier, 2010, pp157).
Marzillier’s commentary on the normality of depression and disorder (even amongst practitioners) is heartening – like Jung’s concept of the wounded healer (Burns & Burns, 2009), it allows a place for our damaged humanity.
Marzillier notes the utility of illness – the function of disorder within the family dynamic, both as identity and escape (Marzillier, 2010, pp 47). I find this a useful adjunct to the idea of the ‘identified patient’ (Agazarian, 1999) – rooting disorder in the family and social system, rather than ignoring the environment in which suffering emerges. Specifically, the power of obsessive compulsive routines to control those around the client is something I’ve witnessed in group psychotherapy.
Marzillier’s difficulties in not offering practical help to his clients when he begins practicing psychoanalsysis (Marzillier, 2010, pp145), mirror my own. This links in with his frustration at the avoidance implicit in the orthodox Freudian analysis he receives as a client, which fails to penetrate a surface relationship and is allowed to become a cursory exercise (Marzillier, 2010, pp195).
The chapter on boundaries ‘getting too personal’, is informative in showing that boundary violations can be as much about wanting to do something to help the client (unconsciously treasuring their approval) as taking advantage of them (Marzillier, 2010, pp 239). In the subsequent chapter Marzillier focuses on ‘the unanswerable question’ of what drove one of his clients to suicide – highlighting impulsivity, life history of failure and conflict, and inescapable patterns of negative feeling and thinking. Again the theme of unwillingness to disappoint the client, to disillusion them, arises (Marzillier, 2010, pp251).
It’s useful to note that Marzillier takes three to four sessions to decide whether to see and how to treat a client (Marzillier, 2010, pp 242). After which he offers a written formulation (essentially a case study) to his client (both psychoanalytic and cognitive aspects) and discusses potential treatments. This emphasis on disclosure and informed consent has impacted on my psychotherapeutic practice.
Writing a book like this, so deeply rooted in subjective life experience, skipping forward and backward through memory is inarguably inexact and inscrutable. However, this kind of ‘romantic science’ (to use Oliver Sack’s phrase) (Wasserstein, 1988) has the capacity to include aspects of the lived experience of the practitioner that more rigid / theoretically driven accounts leave out.
It was fascinating reading about Marzillier’s encounter with the ‘desk drawer problem’ in scientific research – where studies that fail to find an effect (rather than serving to demonstrate the lack of one) rarely have an impact.Interesting too, was his experience of parallel process in the supervision relationship (Marzillier, 2010, pp158).
The books weakness is Marzillier’s relatively privileged clinical position – he generally doesn’t work with (or write about) about intellectually or physically disabled, extremely socially deprived or at risk clients, geriatric, children or adolescent clients: Essentially excluding most ‘front line’ clients of publically provided psychotherapy today.
Marzillier’s self deprecating description of a career in psychotherapy is deeply entertaining. His points about the arrogance of applying evidence based therapies regardless of the uniqueness of the client in question are well made. By charting his own course from behavioural to cognitive and finally psychoanalytic therapy, Marzillier makes a convincing case for developing a therapeutic practice that suits the individual practitioners style of relating; and finding value in a variety of techniques. Finding a way of working he could ‘identify with’ was most important in his development as a therapist (Marzillier, 2010, pp211). Marzillier rejects the systematisation of technique as costly and time consuming (Marzillier, 2010, pp99), and his own career reflects the truth that pioneers have the freedom to make mistakes, and hence the freedom to grow and develop. His experience evidences the importance of allowing therapists to learn ‘on the job’, in a scenario where their developing learning can be put into practice as they become ‘agentic’ practitioners (Bandura, 2001).
I share the author’s distrust of ‘doctrinal’ aspects of psychoanalytic orthodoxies (Marzillier, 2010, pp 212), and other rigid forms of therapy. Marzillier successfully argues for the importance and utility of finding meaning in suffering allied with change (Marzillier, 2010, pp213). The advantage of ‘time to listen’ (in long term, private therapy) provides Marzillier with an open ear to client’s evaluations of their own problems, and the underlying problems they sometimes conceal (Marzillier, 2010, pp217).
Marzillier has built a therapeutic methodology that seeks to combine the best elements of the various aspects of his training background. The book is convincing in its invocation to build a toolkit with which to as Marzillier puts it, citing Yalom, ‘create a new therapy for each patient’ (Marzillier, 2010, pp220); to operate from an unknowing place, but an empowering one – respectfully focusing on the avowed problem (Marzillier, 2010, pp223) without blinding oneself to deeper causation, providing containment (Marzillier, 2010, pp 248) without constriction. All this is demonstrated by Marzillier’s treatment of ‘Cordelia’, a client who presents with panic attacks, later revealed to be stemming from deeper problems (Marzillier, 2010, 227).
The book finishes by focusing on the importance of the personal factor in psychotherapy (Marzillier, 2010, pp260), of the personality and humanity of the practitioner; and the utility of providing a ‘secure base’ even when cure is impossible.
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