This Therapist's Journey in Understanding Ambivalence to Change
Linda Paulk Buchanan, Ph.D.
I am a psychologist and my professional journey began in the 80s when I was getting a master’s degree in counseling. Wait a minute. Imagine that you can hear sound effects of a tape rewinding (for those of you old enough to remember that sound and if not, maybe you can imagine a car breaking and going in reverse). Because I have to say that my professional journey began much earlier than my formal education. I have always been an integrative thinker. That’s how my mind has always worked. I want to see commonalities, compromise, and agreement in everything. I love thinking about how all psychological theories overlap and could conceivably be integrated into one whole. I used to fantasize about being the one who came up with the master integrative theory of psychotherapy. I bet there are a few of you nodding your heads right now.
One of my earliest memories points to this aspect of my personality. This was when I was about three years old and before the time of toddler car seats. I was standing up on the floor board of the back seat with my head stuck over the front seat between my parents. They were arguing about how to pronounce the word pecan. My father being from South Georgia, pronounced it with the accent on the first syllable and the second syllable pronounced the same as a tin can (PEcan). My mother, having grown up in Atlanta pronounced the word with the accent on the second syllable and the a in pecan sounding like ah (peCAHN). As is often the case, simple arguments can spiral into larger arguments and the tension was beginning to rise in the car. After listening to them argue for a few minutes, I piped up and asked why we couldn’t just say PEcahn or pCAN. This story is easier to follow when you can hear the words pronounced, but suffice it to say, I was coming up with a compromise that borrowed from both of their preferences. Their reaction was immediate and highly gratifying in that they chuckled at my creativity and the argument ceased. I learned two things: Finding compromise or balance was very helpful and nothing feels better than making people laugh. I believe in that moment my destiny to become a psychologist was sealed.
Throughout childhood, I had many more opportunities to practice my untrained attempts at care taking. My parents did not see eye to eye on lots of issues beyond how to pronounce the word pecan. I eagerly became triangulated in their arguments though typically at my own expense. I would try to help them see something from the other’s point of view. But since it was unpredictable whether this would be appreciated or resented, my need to help became laced with anxiety. When it helped, however, the reinforcement was very strong and rewarding. Looking back, I was doing what I now call falling into the split; the disconnect or chasm that exists between two people (or within a person who is ambivalent) when they are at odds. It is not a comfortable place to be but as therapists, we often find ourselves there.
Additionally, I was the oldest of three children and at about the age of three, my military father told my siblings I was in charge. Needless to say, I developed into a bossy, little girl who thought that she was supposed to tell everyone what to do - even my same-age friends. That did not make me the most likable kid on the block. Fortunately, I began to understand my error, in large part to my best friend who was an only child. She told me in no uncertain terms that I better stop telling her what to do! So I changed my behavior. However, it took years or decades even to unwire the feeling that I was supposed to tell people what to do. Imagine how that fits in with becoming a therapist.
I was also a very sensitive child (I still can’t watch bloody movies) and my level of empathy was so high that I often felt physical pain. I remember sitting in a large college classroom one day and a girl came in after me. She sat down in the chair in front of me looking very dejected. I felt a strong sense of pain for her. I realized that my reaction wasn’t normal and that I might be feeling even worse for her than she was for herself. I had been teetering on psychology or journalism as majors and this awareness of my own high level of empathy swayed me into declaring my major course of study and my life’s work.
The first counseling (though still untrained) split that I fell into happened when I was working as a youth director in a church. I was 22 and had a bachelor’s degree in psychology. A young girl in my group would talk to me about her mother and I would be very compassionate and make statements like “I’m so sorry that she treats you that way,” etc. This girl would then, of course, go tell her mother what I said. Her attendance started dropping off at youth group functions and I sensed some angry stares from the mother in church services. I was too young and inexperienced to understand what was happening. In my naive mind, I assumed that her mother would just be thankful that I was taking time to be with her daughter.
After leaving the job and going into my master’s program, this situation continued to bother me and I took the opportunity to explore it in a class exercise practicing the empty chair technique. I played myself and then switched chairs and took on the role of the mom. In this role, I started saying things such as, “When you were only twenty-two years of age, you judged my parenting, and do you know how insulting that is?” “My daughter is fairly volatile and can exaggerate; did you ever think that she might have been exaggerating to get your sympathy?” “Did you ever come to me with your concerns?” “Your compassion actually made my job as a mother more difficult.”
I was flabbergasted at the things coming out of my mouth. Apparently, on some level, I may have sensed some of these things, but I hadn’t been aware of it until using this technique. I had royally fallen into a split. Most teenagers don’t feel understood by their parents and this is, to a large extent, normal. And, of course, parents make mistakes (this mom wasn’t very outwardly affectionate). However, my offering empathy to the daughter had not helped the situation at all. I began to realize that unless I was actually prepared to help one person separate from another, falling into a split just widens the gap and has the potential for making things worse for the people involved. This hurtful experience created in me a sensitivity for recognizing that people live in systems and are often ambivalent. Therefore, having been primed (through physiology resulting in a very sensitive nature as well as early learning) to enjoy or even crave integration, I searched for ways of applying integration in psychotherapy. But I still had so much to learn!
Even with this insight, I still was lured into attempting to tell people what to do. In graduate school, I observed that although we were taught that we shouldn’t give advice, most therapists fell into it. Even the very concept of psychotherapy seemed to carry with it the idea that we know what will make people mentally healthy. I had a paradoxical desire to stay out of the middle of their dilemmas while simultaneously needing to help people change (both formed in childhood). I think at this point, I thought that I would just learn to give advice with finesse so that it didn’t really look or feel like that’s what was happening.
In my master’s program, we were taught Rogerian or Carkhuffian style listening (Carkhuff, 1972). I actually had to take three courses, called Helping Skills, devoted entirely to these skills. I remember thinking throughout the first three courses that I couldn’t wait until we could take courses that would tell us how to actually bring about change in the person. I thought of these skills as just the rapport building skills. Once we established rapport, we could get on to the real therapy. Somewhere in the last course, it clicked. These skills went far beyond building rapport or buying time when you aren’t sure what to say. They offered a unique way of empowering a client to hear themselves out loud and to access their own wisdom. For example a Carkhuffian statement might be, “So you feel lonely and frustrated because you want to meet people but you can’t get over your anxiety about being judged.” Or “You feel torn because you want meaningful relationships but you can’t believe that people won’t hurt you in the long run.”
I think these courses helped me recognize that the less I appeared to be doing the work and the more work the patient was doing, the better. This came as a huge relief on some level to me. The kid that had tried to help her parents improve their relationship loved this idea. The anxiety that I had felt as a child would bleed into the therapy relationship when people were stuck. It felt as if I would be blamed and responsible for this. Learning active listening got me off the hook to some extent when I was using it. I didn’t have to try hard to get people to change or take my advice. I could help them find their own answers. I love the quote by Alexandra K. Trenfor, “The best teachers are those who show you where to look but don’t tell you what to see.”
This strategy helped me stay out of splits when working with individuals but I absolutely hated doing couple’s or family therapy. Each part of the couple or family naturally wanted me to take his or her side, a reenactment of what I tried doing for my parents. This was very reminiscent and uncomfortable for me. My sensitive trait and my family dynamics produced in me a high level of perfectionism so I couldn’t allow myself to be content doing individual therapy alone. After four years of working with a master’s degree, I pushed myself to learn more by going back to graduate school for a doctorate. Oftentimes people ask me why I went on to get a doctorate and if truth be known, the main motivator was because it was there to be done. That’s how perfectionists think.
Another significant factor which influenced my decision to go back to school was that I “coincidentally” developed a specialty in treating eating disorders, if anything can ever actually be called a coincidence. I was working with a person who was in a support group for eating disorders which was ending and she told her peers about me. Suddenly, I had six people diagnosed with eating disorders in my practice. I hadn’t known much about eating disorders except that I had heard it was a problem area that was very difficult to treat. Uh oh, trigger my inner recovering perfectionist! I began to read everything that I could about this population in an attempt to stay one week ahead of them in our sessions. They were all doing fairly well so I naively assumed that I was amazing. But here’s the truth. The group that they had been a part of was actually an aftercare group in a psychiatric hospital with an eating disorder unit. They each had already had significant treatment for their disorder. Although they were still struggling and I was helpful, it wasn’t quite as impressive as I thought it was. Secondly, most people with eating disorders are perfectionistic, highly sensitive and severely ambivalent. Sound familiar? Although I hadn’t had a diagnosable eating disorder, I had struggled for a time with food and body image issues. These were my peeps!
But as I continued to specialize, I recognized my limitations. I needn’t to learn more and I needed to address my reluctance to do couple’s and family therapy. So back to school I went. I choose a program which offered a cognate in family therapy. In these classes, I learned how family systems, like individuals, have parts with differing wants or needs. I was taught about how systems that are functioning well have many distinct parts that are working together as an integrated whole but that those that are dysfunctional have splits, triangles, coalitions and unhealthy hierarchies (a bit like my family of origin), which serve to prevent the healthy functioning of each part. The skills that I learned in helping families resolve their differences and in understanding how parts function best as part of a whole further informed my understanding of working with resistant or challenging clients. Similarly, I studied Imago Therapy which taught me the skills needed to resist taking sides with one member of a couple (or as I had done as a child, try to show them the other’s point of view) and instead coach them on resolving the conflicts and ambivalence between the two parts of the couple.
Incidentally, or not really, I met my husband in graduate school and he definitely was not a perfectionist! Although he was working on his doctorate, he embodied the play hard/work hard mentality. I had the work hard part down but had never been very good at play. The saying “It’s never too late to have a happy childhood” became real for me after meeting him. I began to learn balance between play and work. He told me that he never aimed for the highest grade in the class which shocked me. Wasn’t that everyone’s motivation? His was much more adult as he taught me to learn for my own gratification rather than an external reward. I discovered that it took much less time and work to shoot for a 90 (in my program that was an A) than a 100. I made boundaries that I would never study on the weekends or after 6:00 on weekdays with the exception of finals week so that I could focus on enjoying life and our marriage.
With what I was learning in school and from my husband, I began to feel more grounded in the psychotherapy that I was conducting with individuals, families and couples. I was much better able to focus on the moment rather than the outcome. I learned and developed some specific strategies for staying out of splits regardless of where they occurred; within a person or between persons. Upon graduation with my Ph.D. in 1993, I founded the Atlanta Center for Eating Disorders. At the time, there were no IOP or PHP levels of care for this population. There was inpatient or lone psychotherapists. It seemed to me that most of these individuals needed something in between. The program grew to three locations before I sold it in 2017 to Walden Behavioral Care.
Over the years, working with people with more severe eating disorders, it behooved me to develop excellent skills for dealing with ambivalence. Possibly more than with any population, the very thing that is making them feel as though they are good enough, is killing them. Most of these individuals have very deep seated ambivalence which must be harnessed and resolved through integration. This ambivalence often causes much disruption in interpersonal relationships as well resistance to change.
I have developed a career of psychotherapy, supervision, writing and training in which I try to express the point that we shouldn’t take a side when listening to our clients! I’ve continued to enjoy finding theories and strategies which support my love for integration. Over time, I integrated the things I had learned academically and from my clients into a theory about change and resistance to change. I became fascinated as to why people would pay good money and spend valuable time seeking change, just to resist doing what I knew would help them. Eventually, I became more fascinated with resistance than outcome, realizing that dealing with resistance is actually the meat of the therapy. This took the pressure off both me and my clients and things improved more rapidly in most cases.
Therefore, after specializing in ambivalence for 30 years, I published a book to help therapists learn to stay out of power struggles and splits called Pathological Ambivalence: How to be on Your Clients Side without Taking a Side. It was my hope that this book would help therapists feel more grounded in the face of resistance thus greatly increasing job satisfaction. For me, it’s been the culmination of the journey of dealing with my own ambivalence about my role and responsibility as a psychotherapist and the deep seated need to help people while conversely feeling anxious of the responsibility. It’s been the journey of teaching my inner child that she can be helpful without telling herself that she has to be in charge, fix things or take a side. So go out and play!