Jeremy Safran - A remembrance of a clinician/researcher.

Dr. Jeremy Safran, a psychoanalyst and clinical researcher, died this week in a random act of violence.  He was killed by an intruder in his home in Brooklyn.  The piece below was written about three years ago based on my one and only meeting with him, when I interviewed him to write a brief biography about him for a professional publication.  The discussion ended up being about the relationship between clinical practice and research.  It was wonderful to spend time with him and to get to know him.  I regret not having spent more time with him since then – something that now can’t be changed.

     The intended focus of the conversation was the relationship between research and clinical practice.  Dr. Safran talked about becoming a therapist more generally and then on how engaging in the process of research informed his clinical practice, on many different levels.  The most fascinating aspect of this, to me, was that he talked about learning how to do therapy from listening in his role of student and then as researcher to the work of other clinicians.  He said, in essence, that he “borrowed” interventions – not necessarily particular words, though it could be that, but relational attitudes toward patients in particular situations where these had been modeled to have a particular effect.  In some sense, then, Dr. Safran’s development as a clinician has been the result less of having incorporated edicts derived from his or other’s work, and more from being exposed to the clinical thinking and functioning of others and integrating that into his own idiosyncratic approach to the treatment process.  Dr. Safran seems to be saying that you should make your own therapeutic mélange of whatever you are exposed to – whether that is research, supervision, or observing others interact.  But I am getting ahead of myself.  Dr. Safran began the interview by introducing himself and talking about his development as a clinician and as a researcher.

    If you had asked Dr. Safran in high school what he was going to be, he would have said that he was going to be a journalist.  “I like writing,” he said.  When he first went to college, he enrolled in a liberal arts curriculum, did not major in psychology, but he was reading a lot of Freud, Erich Fromm, and other “popular” writers on psychology.  He dropped out of college in the middle of his first year, leaving school for a couple of years and moving from Calgary to Vancouver to live with his cousins.  He reflected that he did not have a plan – his 17 year old daughter thinks about what she is doing, while at her age, he did not.  He went on a long and winding trip from Vancouver to Mexico that included a stop in New York where he picked up more books on psychology.  He began to develop a notion that he would like to be a therapist someday.  His father had died when he was twelve years old.  “I’d been through something painful.  There was a sense that I had grappled with things… I think I betrayed a precocious wisdom; my friends picked up on that and turned to me for advice.  I felt older.”

     Safran eventually enrolled in college again in Vancouver and this time he majored in psychology.  He read widely – about experimental psychology, but also clinical work, including R.D. Laing whose humanistic treatment of schizophrenics led him to read Sullivan, whom he found fascinating.  At about the same time he became interested in Buddhism and compared the Sullivanian self-system with the Zen Buddhist system.  Safran recalls “There wasn’t much in the way of psychoanalysis in Canada.  The little exposure I had had to do with Ego Psychology which I read and which I didn’t find particularly engaging or interesting – I was more taken by existential thinking – the whole theme of people being able to communicate with each other through intersubjective relatedness…  I got interested in strategic interventions; Bateson, Jay Haley, Milton Erikson.  I was interested in using hypnotism and strategic interventions.”  He had an image of the therapist not just as a helper, but as a wizard – so he thinks now that there must have been some sort of power motivation in there.  He was not particularly focused on going to graduate school and was a “middling” student, skipping classes, but reading broadly.  He notes that he was at a liberal arts college and got away with murder, but also learned a great deal on his own terms.  He applied to a few programs, was initially rejected by all of them, but eventually gained admission when another student did not follow through on the position offered. 

     Safran recalled, “It was a behavioral program.  I had nothing but critical feelings about behaviorism...  I got accepted knowing that I didn’t belong there.  I was at the bottom of my class.  The courses were terrible.  There was no clinical training.  It was absurd really.  I basically thought I wanted to learn therapy, so I volunteered at a suicide prevention place.”  He went to the homes of two suicidal people, and realized that he had nothing helpful to offer individuals who were truly suffering.  But there was a new faculty member in counseling education, Les Greenberg, and someone told Safran “This guy is good, you should get to know him.”  He sat in on a course that Greenberg taught, “Theories of Psychotherapy. “ Greenberg was a psychotherapy researcher, and “he had me thinking about how to do research which is meaningful for a clinician.”  He was also trained as a Gestalt therapist. “He and I collaborated.  I found I had an interest in theory and I had an ability to write. How I ended up in academia when I had no interest in academia was because we had this relationship and were writing these things, and struggling with concepts that were not straightforward.”  He wrote with Greenberg about theories but did not join him in doing psychotherapy process based research.  At that time, cognitive therapy was just beginning to emerge and, “with all my interests in psychoanalysis and existential psychology, at least the cognitive folks were interested in the mind… [I realized that] one of the ways I could contribute was to learn cognitive psychology.”  He went on to write articles with Les Greenberg on refining cognitive therapy theory by bringing in ideas from cognitive psychology and emotion theory.  And then, based on a seminar with Jerry Wiggins, he wrote about refining cognitive therapy theory with ideas from interpersonal theory.

    Academically, Safran’s dissertation was not in psychotherapy at all, but rather in social cognition, which was an emerging area at the time.  It was well received, but as a friend asked him, “Isn’t this something that we already know?”  “Yes,” he responded, “but we still have to demonstrate it.”  Despite his public defense, privately he had limited belief in research and believes it possible that he could easily have not done research.  “I was pretty cynical about research… I’m not sure I was a true believer in research.  I’m not sure I am one now.  I wanted to do something meaningful.”  This is where Les Greenberg enters the picture again.  Greenberg worked with Safran to identify, in videotaped psychotherapies, ruptures in the alliance, and then to listen to how they got repaired.  Safran worked to develop a qualitative model, which in many ways has been the core of his empirical research program since then.   

     So, how did he learn to do therapy?  “The cognitive therapy and behavioral therapy I was learning, I just couldn’t use it, I couldn’t see how it would be helpful to anybody.  I wasn’t learning anything from my professors.  I was in a couple of Gestalt Therapy training groups with Les Greenberg.  I thought he was a pretty skilled therapist, I watched him.  I saw what he was doing.  I watched carefully.  I saw what seemed to be helpful and what wasn’t.   I was reading widely – I’d started to read Merton Gill and Heinz Kohut, a little bit of Kernberg.  I did not have any clinical supervision that I found helpful.  None.  I don’t think I’m a very good candidate for clinical supervision.“ 

     Safran moved to Toronto and joined a Gestalt therapy group with Les Greenberg’s mentor.  “I was watching what he was doing.  He had some sort of brilliance about him.  He had this finely attuned sense of what was happening in the moment.  He could really track it.  This keen, intense ability to see something that was happening and pick up on it just as it was emerging.  The incredible laser-like quality of his attention was phenomenal.”  In addition, Safran was seeing a lot of patients, reading a lot, observing himself, and writing, which allowed him to put it all together.  “In many ways I was doing therapy that was consistent with the contemporary relational psychoanalytic sensibility, but heavily influenced by the experiential sensibility and focusing on unpacking what’s happening in the here and now; very process oriented; very light on interpretations.  It had much more of a kind of exploratory quality to it.  And I was writing, and my writing helped inform – helped me think – about what I was doing.”

     The other thing that Safran sees as critical is that while Greenberg is a theorist, the other therapist that he had seen in action was not a theorist – he demonstrated an implicit knowledge of what he was doing.  In terms of his research, Safran was interested in articulating the implicit knowledge of the skilled therapist; working from what the therapist “knew” how to do to describing this knowledge in a way that was transferable to others whose intuitions were not yet as keenly developed.  The process of turning that implicit functioning into another language, something that is communicable, is something that he has tried to do in his research program.  And the process of doing this helped Safran, himself, learn how to do therapy.  He believes that not a lot of psychotherapy research does that well, including , often, his own, but that is where the real gold is.

     In 1990, Safran moved to New York and took a teaching position at the Derner Institute.  He was a cognitive therapist by formal training, but he felt that he needed analytic terms to be understood in the heavily analytic environment of New York.  He had never seen a psychoanalyst, but was now interacting with analysts all the time. He started analytic training, and began translating his work more and more explicitly into analytic terms, and at some point psychoanalysis moved from being a second language to being his own.  He was mentored and supervised by many people, but again found this to be less helpful than he would have hoped.  He enjoyed supervision with Steve Mitchell.  “We would have fun – we were playing with ideas.  I had a number of other supervisors, well known in the field.  They weren’t paying attention to me or what I needed.  They were spouting their theories.  I could read their books to find out about that.  I had read their books.  They weren’t speaking to my needs with this specific patient right now.”

     Dr. Safran, then, is someone who has developed as a clinician less as the result of having emulated others in a passive way, through a process, for instance, like imitation, but he has been able to incorporate the ideas of others into his own unique perspective by actively including them in his writing as he has struggled to articulate what it is that is taking place in successful psychotherapeutic and ultimately psychoanalytic interactions – his own and those that he observes in his research. 

     When I met with him, Dr. Safran was teaching and supervising and he stated that people find his supervision helpful.  People vary, and he saw that he was on the far end of needing to do his own work.  Students of his would use his words – he saw them as not yet being themselves in the moment, so that they would say what they have learned in supervision or say explicitly, “As Dr. So and So would say…”  On the other hand, there was the Gestalt therapist in Toronto whom he emulated, and Dr. Safran would hear the interventions of this therapist coming out in his own practice for years and he would think, “Wait a minute, that’s not me.”  There was this embodied sense of taking on the work of this other person.  He recognized within himself the importance of modelling – of learning from what others say and do, that helped him grow as a therapist.  While this occurred in watching this particular therapist, it happened most frequently in the process of doing his research.

     The value of research to Dr. Safran, as I hinted at the beginning of this post, was doing the research.  It allowed him to think about things and to see things from a different perspective.  Doing clinical research, watching tapes, thinking about what is going on in the consulting room, thinking about how to operationalize concepts; all of this helped him to get a clearer understanding of what should take place in a therapy that is likely to have a good outcome.  When he surveyed researchers, they actually rank reading research pretty low in terms of the impact of that on their own clinical practice, while doing research helped them, from their perspective, become better clinicians.

     Dr. Safran was not influenced by outcome research.  He believed it to be necessary.  He thought that we need it to show other people that psychotherapy works.  But it is not likely, from his perspective, to help us do our work.  But, in general, outcome research, beyond making a case to others of the impact of our work, does not, in his mind, help us become better clinicians.

      On the other hand, Safran said, if you have a research team and you have students or colleagues looking at the same tape, thinking about the same phenomena, and not just theorizing, but actually looking at the tapes and talking about it – the process of studying with others adds a layer of understanding of the psychotherapeutic/psychoanalytic process that you can’t achieve with theory alone.  There is a richness that comes out of that.  Unfortunately this richness is not generally shared with the world at large – the process of doing research can get lost in the process of reporting the results of the research. 

     When we listen to actual tapes of treatment, Dr. Safran believed, we become charitable about the work.  Every now and then someone does a brilliant thing, but for the most part the work is more blue collar.  When I met with him, he was going through an archive of cases with brief relational therapy – a 30 session protocol that was being taught and recorded fifteen years ago.  Based on outcome measures, the treatments were broken into good outcome and bad outcome cases.  He was watching the good outcome cases with his research team and the students were saying that it is terrible work.  And he agreed that the work is not what we might do from the vantage point of the contemporary observer but something of value is happening between the therapist and the patient.  So the challenge to the raters is to understand what it is that is occurring, and also to realize that there is a much broader spectrum of what is useful than we might believe from one theoretical or even empirically informed perspective.  Good treatment can look quite different from what we might expect it to.  And if clinicians were able to access other’s work, they might become much more charitable about their own work.

     So, one of the things that came out of his work is that the biggest  barrier to doing good work is the idea that therapy needs to be done in this or that particular way.  This can inhibit therapists and prevent them from doing their best work.  Because, in fact, when we listen to effective psychotherapy, we find that there is enormous variance in what people do, and this should empower clinicians to work more broadly rather than more narrowly.  Ironically, then, manualized treatments, when they offer limited or very narrow treatment options (which not all do) may be offering something that is contradictory to Dr. Safran’s empirical experience and, while the treatments may end up being empirically supported, they may not be teaching good clinical practice that will, in the long run, have the best empirical support. 

     There are also restrictions on seeing and hearing therapists doing therapy.  Clinicians can be inhibited about recording their work and privacy concerns also interfere with collecting and disseminating examples of good therapeutic work.  Safran noted that APA has built a massive video archive of therapists working with patients.  As someone who has done a one therapy and a six therapy taped segment for the series, he is concerned about the generalizability of these sessions to other work that therapists have done.  He notes that there are four camera people in the room, and though something can be done of value, it is much harder to do the work when it is being observed in this intrusive way.  Yet it does allow students to see the work that therapists actually do – and some of the warts, as well as brilliant moments, do come through.  

     Of course, another impediment is finding the time to watch the tapes.  In research, such time is built into the process, but actually creating space to do this as part of a training process is difficult.  Further, finding the time to watch the tapes with others to be able to discuss them can be difficult.  It would have to compete with time spent reading theory, discussing current work in supervision and other places, and time spent in more traditional pedagogical pursuits.  It occurs to me that the flipped classroom might be a good way to approach this – in the flipped classroom, students prepare for class by watching videotaped lectures, which they then discuss in class.  In this case, students could prepare by watching videotaped sessions and then processing them in class.

     For more seasoned clinicians, taping their own sessions to listen to in consultation groups – or having senior clinicians present recorded hours as part of their training - might be helpful.  It would also be possible to build a library of clinical hours – easier with audio than with video recording – where the identifying material, such as names and place names, is changed.  In any case, the surprising, at least to me, message from Jeremy Safran could be summarized as something like this;  "Clinicians are good at what they do.  And what they do is not perfect, nor does it need to be.  Listening to, thinking about, and making sense of the work that clinicians do helps researchers, and could help the rest of us, learn to be better clinicians."  

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