Search for the Locus of the Universal Symptom: Re-examination of Hellmuth Kaiser's "Duplicity”
By Jerry Krakowski
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Wilhelm Reich, a member of Freud’s inner circle, proposed that a first step in the course of treating neurotic patients is to pay more attention to their behavior, and subsequently proceed with their analysis. By suspending concerns with the patient’s pathology in the initial phase of treatment, he deviated from traditional psychoanalysis. Hellmuth Kaiser, his student, went beyond Reich by proposing that paying attention to the patient’s behavior, in its totality, is the only step in treating patients — there is no other analysis to be subsequently performed. Readers familiar with the work of Carl Rogers will find similarities to Kaiser throughout this paper.
Kaiser rejected any approach to the therapeutic practice that involved the therapist in making a match between the patient’s thoughts and actions and a model of psychopathology. He further objected to imposing the results on the patient. He rejected any “working on” on or “working with” the patient wherein the therapist guides the patient in a specific predetermined direction.
Kaiser’s ideas have always been exciting and powerful: He made an impression on Freud; he made an impression on Wilhelm Reich; he made an impression on Otto Fenichel; he made an impression on David Rapaport; he made an impression on Karl Menninger; he also made an impression on James Bugental, Irvin Yalom, David Shapiro, Louis Fierman, Alan Enelow and a host of others who became familiar with his body of work and studied with him in private seminars.
It is my position that the foundations of Kaiser’s views on psychotherapy are based on the dynamics that operate in ordinary interactive structures. He was most likely unaware of these structures. Kaiser’s explicit aim was to gain an understanding of the therapist’s role during the therapeutic encounter. He wanted to know how the therapist paid attention to the patient: What did he do with that attention? He did not want to know why the patient came to have the neurotic symptoms he developed. Max Weber once commented that you do not have to be Caesar in order to know Caesar. Similarly, Kaiser’s view was that a therapist did not need to know the underlying psychological mechanisms involved in the patient’s pathology in order to treat the patient. Electronic circuit designers, for example, may not know exactly why electrons move through a wire, but even without that knowledge, they can perform miracles in creating electronic devises. Kaiser observed anomalies in patients’ behaviors that are sometimes subtle and sometimes glaring. He called these anomalies (electron-like-entities), their duplicity.
It was his claim that therapeutic changes can take place by means of a technique of bringing patients’ duplicitous behaviors to their attention. The patient’s neurotic symptoms would progressively diminish and eventually disappear. By means of this process, over time, patients are cured.
Hellmuth Kaiser identified duplicity as the “universal symptom.” Nowhere does he provide a clear definition. The locus of the universal symptom, the underlying dynamic, is in the communicative process between patient and therapist. Kaiser focused primarily on the therapist in this process.
This paper will examine two concepts introduced by Kaiser: duplicity and the therapist’s communicative attitude. Unfortunately, one cannot read Kaiser’s work and use the totality of his observations and illustrations as a primer for practicing his style of psychotherapy. Throughout his body of work, Kaiser provides a variety of illustrations of these concepts. These concepts do not apply to attributes of the patient, nor of the therapist. They apply to a therapist’s approach to a patient’s behavior and to the therapist’s reaction to those behaviors. I offer an interpretation of Kaiser’s concepts using, as a frame of reference, the flow of interaction: not only what the patient and therapist say and do, but also how their behaviors are part of a unique dynamic that emerges in the interactions between them.
Kaiser’s departure from psychoanalysis
Kaiser’s interest in psychotherapy began when he himself was a patient in psychoanalysis. Before he had any formal training, he wrote a psychoanalytic paper, “Kleist’s Prinz von Hamburg” (Kaiser, 1930). Freud read it and sent Kaiser a flattering four-page, hand-written commentary. A few years later, Freud interceded in Kaiser’s behalf and helped him gain admission to the Berlin Psychoanalytic Institute. Kaiser became a psychoanalyst.
Because Freud’s main interest was to develop a comprehensive theory of psychopathology, he did not detail a program for the practice of therapy. At first, Kaiser attempted to fill that void within the framework of psychoanalysis. A number of intervening factors contributed to his taking a different path. Eventually he devoted himself exclusively to the understanding of the therapist’s role in the therapeutic process.
Kaiser (1934) wrote a paper called, “Problem of Technique,” where he began to map his version of an extension within psychoanalysis. This paper was not well received. Subsequently, he no longer addressed psychoanalytic issues. His departure from psychoanalysis was also evident in the literary form he used to convey his point of view.
The last paper he wrote, “The Universal Symptom of the Psychoneuroses: A Search for the Conditions of Effective Psychotherapy,”  is written in the form of a pseudo-biographical novel. In it, the innovative and experimental therapist (designated as “G…”) explored a variety of simple strategies in communicating with his patient. Some changes were extremely subtle. For example, he changed the approach in the opening exchanges in the first few seconds the therapist spent with a new patient from what he had been taught in his psychoanalytic training. The results of these experiments lead to the development of a model for an effective psychotherapy. Included in his program are the following themes:
1. Nothing is required of the patient except his physical presence.
2. All responsibility for the outcome of therapy rests with the therapist.
3. There is no causal connection between the changes that take place in therapy and the topics discussed.
4. The therapist must always be psychologically available to the patient.
5. Psychotherapy is not an enterprise that directly solves practical problems.
In his paper “Emergency,” a second paper that departed from traditional academic form, Kaiser used the form of a seven-scene play. The play depicts a Kaiserian therapist who races to keep another therapist from committing suicide. The play is filled with suspense and melodrama and was designed to illustrate an important theme in Kaiser’s work: Therapy can take place without the requirement that a patient cooperate.
In the play, this premise is pushed to the extreme: The wife of a severely depressed therapist convinces the Kaiserian therapist to accept her husband as a patient by becoming her husband’s patient. The husband becomes the unwitting patient. This impossible (as well as unethical) premise of the play was invented by Kaiser as a didactic device: He wanted to demonstrate some of the principles of his therapeutic techniques – without getting bogged down with theoretical explanations or justifications. One of the main attractions of this format is that his ideas are not clouded by academic jargon. The exposition of his ideas is clear, simple and makes good sense.
Problem: the mystery in the outcome of psychotherapy
The “Universal Symptom …,” chronicles the development of his therapeutic process. At one point, he posed the rhetorical question: “From where does therapy derive its magic power?” The answer he gave was: “… it is located in the ‘therapist’s communicative attitude’.” His use of the term “magic” is jarring since Kaiser was a scientist as well as a clinician. He received his Ph.D. in mathematics and philosophy, before he became a psychoanalyst. His use of the term does not refer to slight-of-hand trickery. The use of the term “magic” calls attention to the magnitude of Kaiser’s awe of the changes that take place resulting from psychotherapy. The term “magic” refers to a mystery in the connection between the application of a therapeutic technique and its beneficial results.
The phrase, “therapist’s communicative attitude” suggests that, in the clinical setting, the thoughts expressed by the therapist are expected to have an effect on the patient. It is obvious that xxx any changes would be achieved through communication. That interpretation is overly simplistic. For Kaiser, the “therapist’s communicative attitude” denotes an intimate involvement with the patient and with his universal pathology, duplicity. For Kaiser, an essential part of a therapist’s communicative attitude is the availability to react to the behaviors of the patient.
The magic in the process of psychotherapy cannot be explained by understanding duplicity or the therapist’s communicative attitude. No single event explains the magic of the changes that take place. The magic refers to the result of a series of processes triggered by the mutual reactions between patient and therapist. Neither duplicity nor the therapist’s communicative attitude exists outside the therapy session.
Illusive aspects of Kaiser’s ideas
Kaiser was aware that he did not provide a clear description of his ideas. In his introduction to “Emergency,” Kaiser in Fierman, L. (1965), Kaiser acknowledges his awareness of the vagueness in how he presents his ideas; those remarks apply to his concepts of duplicity and the therapist’s communicative attitude as well.
The views [expressed in this paper, “Emergency”] ... are my views. They are not easy to present or to transmit, not because they imply a complicated theory, but because they are simple where one expects the elaborate. When they are expressed in abstract terms, as a textbook would do, the reader is likely to miss their meaning, as if he had to decipher a melody from the grooves of a gramophone disk.
Kaiser in Fierman, L. (1965), p. 172
He presented his ideas about therapeutic methods indirectly. Purposefully. Kaiser was quite capable of doing otherwise, but did not use the form of a scientific paper. The reason was that the phenomena he dealt with were ephemeral: the perception and reaction to anomalies in an on-going course of interaction that contain the simultaneous expression of two attitudes. These anomalies, because they occur during the on-going interaction, are fleeting. They can easily be missed.
Kaiser’s ideas about this dialectic -- the interplay between the attitudes that shape a patient’s behaviors and the therapist’s reactions to those behaviors, cannot be specified directly.
Duplicity and reacting to Duplicity
The following is an imaginary speech by Freud. It was created by the author as an indirect means of looking at some of Kaiser’s central ideas. In a more direct approach, each sentence in the speech would require an expansion into several pages or chapters. The speech also places Kaiser’s work in historical perspective and raises some clinical issues.
Freud, in the 21st Century, mysteriously appeared at a psychological conference and addressed not just psychoanalysts, but therapists of every persuasion. He began by defending himself against various writers who besmirched his personal character. Their intention was to cast doubts on his intellectual achievements. It seemed that his speech had ended when he suddenly smiled in anticipation of the strange words he was about to utter. He took a deep breath, shook his head, and said:
“… Look, you paid too much attention to what I said and did not pay sufficient attention to what I did in the course of treating my patients – especially early on. At the outset, I was not concerned with rules and did not have many theories.
I listened to my patients for hours and hours and allowed them to speak with very little interruption. Eventually I got to know what Wilhelm Reich called each person’s “character.”
On rare occasions, I noticed peculiarities in my patient’s behavior that I had not anticipated: Sometimes, a patient would laugh in mid-stream of a sentence (it was not laughter that was in response to a joke); sometimes his words would assume a voice that was completely out of sync with his personality (timidity in the midst of anger, or proclamation of poverty when he had a sizable bank account), etc. Their behaviors were bizarre -- but not by reference to some model of ideal mental health. During those exceptional moments, my attention was attracted to what my patients did, and not to an analysis of their neuroses.
Even my own behaviors at those moments were puzzling. I found myself laughing when the subject of a patient’s talk was serious. My patients never found such laughter disrespectful. No disrespect was intended. At times, I offered caricatures of his behaviors: “You are talking as if you can’t get off a speeding train fast enough;” or “You sound as though you are a spy, but no one told you what you are supposed to be looking for.” I see now that those caricatures were metaphors capturing the essential qualities of strange behaviors.
Therapy as usual had been temporarily suspended.
These special instances were unique in other respects as well. My comments, which seemed so frivolous and incongruous when examined out of context, had an impact on the patients and provided them with images of how their attitudes shaped their behaviors. During those moments, patients responded as if something very profound had been revealed. My bizarre comments, while essentially true, were valid only then and there.
I never wrote about these unusual experiences. It was not clear to me why these peculiar interchanges found their way into the therapy hour in the first place. Introspection was of no avail.
I described and analyzed a related group of unusual and puzzling behaviors in my Psychopathology of Everyday Life: “Slips of the tongue” and “the contagion of forgetfulness” are two examples. These unusual and unexpected behaviors were not noticed until I drew attention to them. In that book, I explained their connection to the subconscious.
The entire collection, of all the unusual behaviors, has a feature in common: The interactive context is an underlying factor.
Wilhelm Reich had a student, Hellmuth Kaiser, who turned his attention exclusively to these peculiarities. The events I noticed only infrequently, Kaiser found ubiquitous. The reason is that I was distracted by my zeal to search a patient’s “materials” for evidence consistent with my theories and did not pay attention to the patient in his totality.
Kaiser’s view of the therapist’s role in therapy differed from my own.
I advocated analyzing the patient’s pathology: In my view, the therapist guided the patient towards an understanding of his presenting symptoms as aspects of his pathology. When, for example, a patient gained insight into his pathology, this represented to me an improvement in his mental health. In contrast, Kaiser's position was that he had nothing to teach patients about themselves. When his patients expressed insights, he regarded these as no different from any other clinical material. He did not encourage his patients to gain an awareness of their pathology. What Kaiser did do was to point out to his patients the simultaneous presence of two attitudes exhibited in their behavior. This he called the patient’s duplicity.
Kaiser observed that patients are never consciously aware of their duplicity. Duplicity is always invisible to the patient and only achieves a reality when it is reacted to and described by the therapist.
Another point of divergence between our viewpoints is that I considered the patient’s cooperation an essential component of the curative process. In Kaiser’s view, there was nothing the patient could do to accelerate his own treatment and no cooperation was required. Without requiring the patient’s cooperation, in principal at least, it did not matter to Kaiser whether his patients were truthful or deceitful.
From Kaiser’s perspective, the therapist was merely a catalyst: Changes in a patient’s symptoms were the result of the cumulative experiences in the patient’s communication with the therapist.
Freud paused, looked out at his audience, smiled, and his changed tone of voice signaled he understood their surprised reaction. He continued to smile as he said:
How strange it would feel to one of my patients if he were to enter into treatment with Kaiser. How strange it would be for the patient not to be asked to bring in recollections of dreams. How strange it would be for the patient not to be asked to speak with wanton abandon. How strange it would be for the patient not to collaboratively review, with meticulous care, a history that provided clues to lost memories of a traumatic past. How strange it would be for the patient not to view his thoughts and actions as symbolically connected to past events and relationships. How strange it would be for the patient to leave all the work of treatment in the hands of the therapist.
With those words, Freud suddenly disappeared.
There are several unanswered questions posed by this fictitious speech: What are the anomalies in a patient’s behavior? What is duplicity? How is Kaiser’s idea of a therapist’s communicative attitude different from other ideas of a therapist’s attitude? How can a therapist be surprised by his own behaviors? How can therapy be anything but a learning experience for the patient?
Kaiser’s perspective on therapy offers novel alternatives that are not direct answers to these questions.
The interactive context and psychology
Kaiser shifted away from a focus on a patient’s psychology (his psychopathology), towards a focus on the therapist and the way in which he attends the patient’s behavior. Psychologists and others have been aware of the minute interplay and influence that actions and reactions have in the course of interaction.
Charles Darwin (1872) observed that the capacity to blush is a characteristic unique to the human species. Blushing reflects an inner psychological state. This reaction is involuntary and is publicly visible. Anna Freud (1946) noted that, in children, expressions of spontaneous laughter are involuntary and provide the analyst with an uncensored picture of the child’s inner state of mind. Harry Stack Sullivan (1954) commented that schizophrenic patients sometimes experience the “eyes as the windows to the soul.” – They feel that others can have access to their innermost states of mind.
How are the experiences -- of blushing, of spontaneous laughter, and of piercing paranoid self-consciousness -- related to one another? Each is an illustration of a dramatic psychological reaction that is experienced or expressed by one individual while in the presence of another. Each occurs within an on-going course of interaction.
Although not using the same terminology employed in this paper, the connection between psychological dynamics and the structures of ordinary interaction were noted by David Rapaport (1967) and by Frieda Fromm-Reichman (1950). Rapaport was aware of the differences between the therapeutic relationship and the interpersonal (interactive) relationship. He made a distinction between two types of perspectives on the interplay between the individuals interacting in the clinical setting:
1. analyst-analysand (a perspective used in psychoanalysis)
2. interactive relationship (a perspective used in sociology)
The interactive context, the arena in which psychotherapy takes place, has a dynamic that is not part of, and therefore distinct from, Rapaport’s concern with a psychoanalytic understanding of the relationship between the participants. Rapaport did not specify the details of that distinction and he did not elaborate on the interactive relationship.
Frieda Fromm-Reichman (1950) was aware that dynamics in ordinary interactions could interfere in the process of therapy. These dynamics can impinge on the behavior of the therapist when he interacts with his patient. She was acutely aware of a natural, spontaneous and compelling tendency on the part of the therapist to search out problems from his own personal experiences when listening to problems presented by the patient: 
What then are the basic requirements as to the personality and the professional abilities of a psychiatrist? ...I would reply, 'The psychotherapist must be able to listen.’ This does not appear to be a startling statement, but it is intended to be just that. To be able to listen and to gather information from another person ...without reacting along the lines of one's own problems or experiences, of which one may be reminded ...is an art of interpersonal exchange which few people are able to practice.... The therapist must avoid reacting to patients' data in terms of his own life experience.... [and] to concentrate upon listening to the patient. [Emphasis added]
Fromm-Reichman (1950), p.7
The interactive relationship, a non-psychological relationship, has relevance within the clinical setting because the participants are engaged in social interaction. Neither Rapaport nor Reichman attribute any pathology to the interactive relationship. Whereas Rapaport was interested in the global aspect of the interactive relationship, Reichman was sensitive to a dynamic within such a relationship. Reichman points to a reflexive reaction that invariably takes place in the clinical setting because the therapist and patient are at the same time participants in ordinary social interaction. The structural rules that apply in ordinary conversation apply to the clinical setting as well. Social structures, like their psychological counterparts (attitudes) influence the minutest aspects of behavior.
Social structures shape behaviors
The following sociological analysis of an interaction between a mother and her child is an example of a situation where an understanding of the words alone would miss a socially structured dynamic that surfaces only in the course of an on-going interaction. While the behaviors of the participants are influenced by social structures, the participants are not aware of the dynamics involved. Similar dynamics apply to the clinical setting.
This exchange takes place in an examining room of a doctor’s office in a hospital:
Mother: What do you say?
Child: Thank you.
When a mother says to her child: “What do you say?” it is not difficult to imagine that immediately preceding his mother’s question, the child was doing nothing. There was a silence. It was a silence that belonged to the child. The mother, however, experienced a sense of urgency during the silence to do something. There was someone other than the child present – the doctor. She heard in the silence, an absence. Hearing an absence is not the same as hearing nothing. A silence in an interactive context is itself an action. Her son’s action, the silence, had a coercive influence on her: It prompted her to ask her question. She reacted to the silence. Her reaction was not an elective act. She could not choose to do nothing. She is compelled to ask her question. It is not enough for the mother to know her child’s repertoire of responses.
At that instant, in the course of the interaction, she executes a cultural imperative. Her orientation is to enforce social norms of politeness. Her behavior is a cultural instrument and she complies as if she were following a mandate to ask her question. The question she asks is not like asking for the time of day. Her question serves as our culture’s device for teaching children abstract thought: to recognize specific instances as belonging to categories that are governed by the application of a rule. Her action, a reaction to her child’s silence, instructs her child: “You need to recognize that this circumstance is typical for similar situations. You need to select an appropriate match from that collection of responses that you already know.” The child’s silence reflects that he failed to acknowledge in a culturally prescribed manner his appreciation in receiving something that qualifies as a gift [the doctor gave him a lollipop]. The mother is predisposed to react to her child’s silence. She does this in compliance with her culture’s expectations as his caretaker. Once the mother’s question is posed to the child, the appropriate response, “Thank you” was made and correctly filled the void.
It is not incidental, but culturally axiomatic, that parents are charged with socializing their children. They are suited to do so not because they have read Dr. Spock, or Amy Vanderbilt. But they are particularly suited to preserve and perpetuate a culture’s social norms because they are positioned to react to transgressions in the behavior of their children.
This exchange could not take place without semantic understanding. This example illustrates structural dynamics within interactions: While a mother orients to issues of politeness, she is participating in a much larger cultural process – teaching abstract thinking.
Krakowski, J. (1968)
While the mother is enforcing politeness, her attention in executing this task is directed towards a narrow spectrum of the totality of the child’s behavior. Similarly, Reichman focuses on a narrow range of a therapist’s attention to a patient’s behavior when she recommends that he exercise control over his natural inclinations as an ordinary conversant to not insert his own recollections during clinical exchanges.
Kaiser’s therapeutic recommendation was just the opposite. He advocated no restrictions in the natural flow of interaction with the patient. . He recommended sensitivity to the entirety of the interactions in the clinical setting. This is part of the therapist’s communicative attitude. He urged that the therapist not interfere with his natural inclination to react to any aspect of the patient’s behavior. In short, he urged a therapist to be himself and not assume a role – that of a therapist.
An illustration of duplicity: a contrast in affect
Duplicity refers to a duality. The selection of that term by Kaiser was unfortunate. It would have been preferable if Kaiser had selected a term from a different language: from French, “duplicite,” or from German, “doppelzüngigkeit.” Terms from a foreign language would not immediately bring to mind familiar psychological processes. Kaiser’s use of the term does not refer to a malady. Kaiser’s use of the term focuses on the therapist’s sensitivity to duplicitous behaviors.
The following is a clinical example of duplicity. It distinguishes between a perspective of a patient-and-his-problem vs. the perspective of the therapist and how he observes-the-patient’s-behaviors. It will be used to illustrate how Kaiser’s approach to the therapeutic process is unencumbered by analytic meanderings.
First, I will present a view that is contrary to Kaiser’s approach. The materials are compiled from a series of the author’s file notes.
He smiled without knowing that he was smiling. 
Kaiser, in Fierman (1965) p.90
In his therapy hour, a patient reported that the night before he had had a bitter fight with his wife. The patient insisted he was right during the fight. He had ranted and raved in his efforts to set things right. There had been an injustice.
He was clearly agitated as he recounted the events.
As he delivered his narrative, there was an increase in the amplitude and pitch of his voice and in the rhythm of his speech. As the narrative proceeded, the therapist noticed a peculiar accompanying feature: Throughout the narrative, the patient wore a plastered smile. His smile was reminiscent of a father who was boasting that the home team had won the championship and his son was the star.
The patient was genuinely surprised when the therapist pointed out the smile. Yet, it was as though the therapist’s words fell on deaf ears: When the patient continued the narrative, the smile immediately returned.
Krakowski, J. (2001)
The two affective components of the patient’s behavior, the smile and the hostility in the narrative, are logically opposed to one another. Were the patient conscious of his smile, that awareness would undermine his insistence that he was right.
Yet the smile suggests that he knows something. It is obvious by watching and listening to the unfolding narrative, that the patient does not know what drives the smile.
To know and not to know – a problem and its resolution
This juxtaposition of affects is puzzling. When the patient smiles throughout the course of a narrative filled with anger and is oblivious to the smile, it poses a putative paradox: There is something the patient both knows and does not know at the same time. How can anyone, at the same instant, both know and not know? 
First, I will present a conjectural exploration of the problem: The patient’s pathology is at the center of the discussion. Then I will present a view of the same clinical situation: The therapist’s posture is the center of discussion (a Kaiserian perspective).
From the point of view of the patient’s perception of himself, this example poses a discrepancy in how he wishes he were viewed by others and constitutes a contrast in the image displayed in his behavior. One explanation is that the smile is prompted by the patient’s anticipation that the therapist will react with surprise at his confrontational behavior in and out of the office. The patient may even feel a sense of triumph. From his viewpoint, his actions in the fight transformed an image of himself as someone with a mundane personality, to someone with a more noble personality: He had stuck to his guns in the face of adversity. In his eyes, with his bold actions, he elevated the stature of the image of his character.
Another approach to understanding this circumstance is that his smile represents the outcome of the patient’s juxtaposition of two contrasting images he has of himself: On the one hand, he sees himself as a reasonable, gentle and kind intellectual; on the other hand, he is aware that his exaggerated and volatile behavior paints a picture of him as a bully. As he delivers the narrative, he anticipates that the therapist will actively see him as a bully as well.
Other viewpoints can easily be imagined that are equally plausible. Such accounts assume that the patient’s reasoning is rational even if his behavior is not. Such accounts are speculative and require making theoretical assumptions. Such accounts are not based on observation.
It can be observed that the patient’s attention is riveted to the fight. His dramatic re-creation revives the emotions he experienced during the fight, and this is dramatically displayed in the delivery of his narration. His presentation in the office seems to be theatrically orchestrated. It is unlikely that he was smiling in the heat of his dispute – but it is not impossible. The smile surfaces the instant the narration begins and but does not stop upon completion of the narrative. The simultaneous appearance of the smile and the expression of anger are alien to him. It is as if an external influence intrudes upon him. The smile has a life of its own.
The paradox is an analytic construct. It is valid, but only under the condition that its components are composed of discrete abstract elements removed from the context in which they occurred.  The paradox involves two opposing ideations: The thoughts that lay claim to the patient’s convictions that his anger is justified and the thoughts that evoke the patient’s expression of apparent amusement. The narrative differs from a monologue, an entry in a diary or a report dictated into a recording device. The paradox fails to take into account that the narrative occurs in the presence of the therapist. The paradox consists of components that have been artificially removed from the interactive context in which they took place.
An examination of the component elements of the paradox, that more closely tracks the events as they transpired, reveals an important flaw in the formulation of the paradox: There is a difference between an ideation and an experience.
The first “know” contained in the paradox refers an experience, and not to an ideation. He does not “know” his experience of the smile. What he is not aware of is not something that he might be thinking, but something his body is doing. The patient reacts with what appears to be amusement and is not aware of his experience of that reaction.
This paradox overlooks a critical feature of language: The same terms in a language can be both precise and ambiguous. The paradox is dependent on the reader’s tacit acquiescence not to notice that the meanings of the term “know” shifts from the first part of the formulation to the second. The first “know” implies an awareness of an experience. The second “know” refers to an obligation to know: He should know the object of the first “know.” The first “know” refers to an analyst’s claim about the presumed cognitions of the patient, and the second “know” refers to the patient’s absence of an awareness of the analyst’s claim. In the context in which the smile took place, the patient does not know that he reacts to something in his environment.
The presence of the therapist affects the shape of the patient’s behavior in ways that are unclear. Independent of any specification of that influence, the paradox failed to take into account that the smile occurred while the patient was talking to his therapist.
The paradox is resolved! Or more correctly, within the flow of the clinical interaction, there is no paradox.
Push and pull, and the communicative attitude
The discussion thus far has explored the patient’s behaviors from an existential and phenomenological point of view. It has explored the patient’s relationship to his behaviors, his attitudes, his experiences, his awareness, etc. The resolution of the paradox is a trivial triumph. The resolution of the paradox does not solve any practical or theoretical problems. Kaiser’s work does not offer a means to solve paradoxes. Furthermore, within his framework, paradoxes involving a patient’s behavior are irrelevant.
A Kaiserian perspective focuses on the actions of the therapist. This clinical example will now be examined from that perspective.
Every therapist watches and listens. It is puzzling why this therapist did not see the smile from the outset. This therapist did not see the smile until the narrative was well under way.
Some therapists never see the smile!
In this and similar circumstances, the therapist’s blindness to the smile does not reflect a shortcoming in his skills as a therapist. The blindness is induced in the therapist as a consequence of the behaviors of the patient. It is as if the patient engages in a strategy to distract the therapist. The patient’s neurotic attitudes guide the course of his actions. Those attitudes are at work in innumerable ways – but they are not haphazard. With his narrative, the patient seduces the therapist into surrendering his attention to the drama of the story. The narrative is told so as to convey a sense of urgency. The patient gives the impression that his interest is singular and focused. The narrative is designed to get the therapist to side with him and to help find a solution to his problem. The patient’s actions are geared not only to have the therapist agree that his claims in the fight were justified, but they are also geared to get the therapist to feel sorry for him. The patient’s narrative is delivered in such a fashion so as to gain a sympathetic ally. His narrative is delivered with a missionary-like zeal.
A friendship has developed over the course of their therapeutic contact. The therapist, because of the patient’s underlying efforts, vacillates between his feelings of friendship towards the patient and his professional responsibility to cure him. Consequently, the therapist is vulnerable. The narrative cloaks a plea for help. The therapist is only human. He succumbs. At the instant he sympathizes with the patient’s predicament, he is blinded to the existence of the smile (perhaps no differently than the patient is blinded to his own smile). Throughout the narrative, not only is the patient upset with his wife, but he is also, at the same time, outraged that he is a victim of her abuse. The successfully seduced and sympathetic therapist will immediately contemplate remedies. If the patient succeeds in winning him over, the therapist acts as a friend. At the point the therapist acts as a friend, the patient has succeeded in distracting the therapist. Unwittingly, the patient impedes progress in his own treatment.
What choices are available to the therapist as an alternative to acting like a friend? What does the cure consist of?
1. The therapeutic cure is not to stop the patient from smiling. To smile in a circumstance such as this is not a malady. The smile accompanies the malady.
2. The therapeutic cure is not to promote an attitude where the patient would feel better about this fight nor to persuade him to stop fighting. Even if the therapist had the power to do so, this path might lead the patient to become overly placid and at the extreme, vegetative. It is not the goal of therapy to break his spirit. 
3. The therapeutic cure is not to persuade him to stay in the marriage, nor to leave it. It is not the goal of therapy to become a surrogate decision-maker.
A Kaiserian perspective would examine the therapist’s role in this interaction.
When Kaiser’s idea of a therapist’s communicative attitude is applied to this clinical example:
1. It does not matter that there is something the patient knows and does not know at the same time.
2. It does not matter why the patient has the problems he presents as his complaints.
Kaiser’s approach does not require that the therapist be able to explain or understand the nature of the “malady.” In Kaiser’s approach, more importantly than anything else (from a practical standpoint of the therapeutic process), is that the therapist not get distracted by the patient’s behavior. When the therapist pays attention to the totality of a patient’s behavior and is mindful of the patient’s alternative attitudinal possibilities, this will increase the possibility to notice the smile.
When the therapist sees the smile, he assumes a posture in which he is disattentively attentive  to the patient’s behavior. He is both an active and a passive agent in that setting. To the extent that he is attentive, he is a co participant in the interaction with the patient. To the extent that he is disattentive, he is a passive witness to the variety of events before him and is thereby available to react to those behaviors. He must do both, simultaneously: assume a posture that is attentive and disattentive.
Kaiser’s therapeutic approach does not focus on interpreting or understanding the content, issues or specific concerns of the patient. Instead, his therapeutic approach views the totality of the patient’s behavior. The approach is optimally designed to allow the therapist to be available to react to any aspect of the patient’s behavior. This is the therapist’s communicative attitude. The communicative attitude does not attempt to get the patient to understand, to accept or to ignore the smile.
The act of pointing out the smile, pointing out the patient’s duplicity, is the curative agent.
A second illustration of duplicity: the shape of behavior
It should not be assumed that because the above example of duplicity involved opposite affects that this is always the case. Opposite affects are but one form of expression of duplicity and not the most prevalent nor necessarily the most interesting.
Duplicity permeates every therapy session. It is not immediately apparent. The smile, for example, was not immediately apparent. When the therapist, like the mother who notices the child’s silence, notices and reacts to the patient’s duplicity, he may, like the mother, feel an urge (culturally speaking), to point it out to the patient. In the following excerpt from a therapy session, there is an example of duplicity. This therapist, Carl Rogers, had never heard of Kaiser.
Rogers was the first psychologist who published the entirety of his therapy sessions verbatim. The following fragment is from Rogers’ (1942) Counseling and Psychotherapy:
C= counselor [therapist] S=subject [client]
1. C: Have you worried a lot about this matter of writing home?
2. S: About this? Well, yes, because it is going to be a pretty difficult proposition to put it across. I have not got any idea of what action they are going to take.
3. C: You sound as though you feel a little bit like a prisoner before the bar.
4. S: (Laugh) That’s just about it.
Rogers, C. (1942) p.136
The therapist’s response in line three to the patient’s remarks in line two is a departure from the style of interaction that transpired before and after this exchange. The therapist makes an observation in line three that takes the totality of the patient’s behavior into account. The therapist’s remarks differ from a variety of conventional possible responses: It does not contain an interpretation of the content of the patient’s statement; it does not contain a connection to the patient’s prior traumatic history; it does not contain advice; it does not contain a perspective of the patient by reference to psychopathology, etc.
If a word-for-word and line-by-line search were conducted on this fragment, duplicity would not jump off the page. Nevertheless, to the therapist in that exchange, the observation he made in his reaction to the patient’s behavior is consistent with Kaiser’s sense of duplicity.
While interacting with the patient, the therapist noticed a combination of elements that led to his impression that the patient was excessively formal. That impression may derive from the manner in which the patient expressed himself: the shape of his delivery, as well as the content of his response to the therapist’s question. In combination, these components conveyed a sense of excessive formality. The disparity between how his attitudes shape his verbal expression and the content of that expression is his duplicity. The therapist points to an anomaly in the patient’s behavior: He speaks with an excessive formality and at the same time does not recognize that formality.
The relationship between the patient and his anticipated audience is that of a son speaking to his parent. By pointing to a formality in his mannerism, the therapist is not educating the patient. More importantly, in the therapist’s act of pointing to a formality, the therapist is not being judgmental or directive.
This therapist’s remarks were inconsistent with his announced model of psychotherapy as described in the first part of his book. The comments he made to the patient at this particular instant fell outside that paradigm. At this instant, the therapist let his guard down and failed to censor his thoughts in accordance with his own theoretical aims.
The duplicity in this fragment differs from the smile-anger example in that it is not a juxtaposition of two opposite modes of affect. It is similar to the smile-anger example in that it illustrates how coexisting attitudes shape a patient’s behavior.
Kaiser’s thinking was not only novel, it was also bold. He sought to enlarge the understanding of the therapist’s function in the process of psychotherapy. Kaiser’s illustrations of duplicity throughout his work do not specify duplicity. The illustrations sensitize the reader to the nature of the phenomenon.
The patient in therapy always creates the impression that he has a singular focus (even when he expresses an awareness of confusion). His duplicitous behaviors betray the presence of alternate thought structures. When the patient’s misdirection of the therapist’s attention is sufficiently effective, the duplicity remains unnoticed by the therapist and the neurotic symptoms remain intact. Duplicity does not reside in the patient. Duplicity lies in the fabric of the patient’s behavior. The nap of that fabric is only accessible to the therapist and only at the instant in which it is expressed.
The beneficial outcome of the process of therapy is brought about, in part, by the therapist’s communicative attitude. There are additional components that have not been broached in this paper. One such component has to do with the reaction by the patient to the therapist’s reaction: The patient does not merely understand the therapist, he reacts to the therapist. The mystery and magic in the therapeutic process is the result of a mutual interplay of reactions.
The elusive nature of the therapeutic process remains: Something in their interaction ensures that duplicity will remain unnoticed, and at the same time, something in their interaction prompts the therapist to notice duplicity. The patient perpetually engages in actions that misdirect the attention of the therapist: This is, in part the universal symptom – the duplicity. The therapist’s communicative attitude is, in part, an attempt at averting that misdirective work in a non-self-conscious and effortless manner.
The locus of duplicity and the locus of the therapist’s communicative attitude is the interactive context.
Jerry Krakowski, is a sociologist who received his degrees from UCLA. He holds an Advancement to Candidacy degree. A student of Harvey Sacks at both UCLA and UCI, he has a continuing interest in Conversation Analysis.
During a Pre-Doctoral Fellowship at the Illinois Pediatric Institute, he analyzed tape-recorded conversations between parents of mentally retarded patients and staff members. Independent of that experience, he developed a strong interest in the psychological writings of Hellmuth Kaiser and David Shapiro. Krakowski found a surprising similarity between their clinical approach to the practice of psychotherapy and his own methodological approach to conversational materials. He has been a research analyst for the past 10 years relying largely on tape recorded clinical materials. The present chapter represents an amalgamation of his interests in psychology and sociology.
He is currently pursuing an expansion of his ideas of Kaiser’s work and analyzing video and audio tapes of Carl Rogers.
He can be reached at: firstname.lastname@example.org
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Yalom, I. (2002). The Gift of Therapy: An Open Letter to a New Generation of Therapists and Patients. New York: Harper Collins.
 Reich (1972).
 Two presentations making a comparison between Rogers and Kaiser were made at a single “Open Space” session of the Carl Rogers Centennial, La Jolla, July 2002: Fierman, L. (2002), and Greening, T. and Krakowski, J. (2002).
 See forward by Enelow in Fierman (1965).
 See Reich (1972), p.310. See Fenichel (1953)
 Kaiser in Fierman (1965).
 He borrows from Kafka’s (1964) The Trial, and uses the same style of a single-letter referent for the main character.
 Fierman, L. (1965).
 Ervin Yalom (2002) in his book, The Gift of Therapy, has a chapter devoted to how patients bring about change in their therapists. Kaiser’s “Emergency” is listed as one example. As a technical matter, the Kaiserian therapist in the play was never the patient -- he only pretended to be the patient. Fierman (2002) has suggested that the reason that three therapists Kaiser, Rogers and Lomas, developed a posture of non-directive therapy is because their patients influenced them to do so.
Fierman, L. (1965) p.162
 His thoughts and actions are a reflection of his reactions.
 See footnote 40.
 Kaiser (1930), (1931) wrote several psychoanalytic papers that were published before he became a psychoanalyst. Kaiser (1931) also wrote a lengthy psychoanalytic paper examining various segments of the writing of Franz Kafka. A small segment appears in Stanley Corngold’s (1972) Metamorphosis.
 The ideas contained in the scenario regarding Freud’s early approach to patients have been expressed in Kaiser’s writings and seminars. A transcript of a seminar given by Hellmuth Kaiser (1955) is available on the internet. While it deals primarily with the topic of Wolfgang Lederer, it contains some of Kaiser’s thoughts on Freud and Freud’s early work as a therapist.
 Sometimes the mere potential for interaction can be sufficient to trigger these reactions.
 Rapaport (1967) states:
If I investigate the relationship of two people, an interpersonal relationship, with a certain method, it is quite possible that the method that I adopt will tell me nothing about the interpersonal relationship. Or it may tell me only something about it … the interpersonal issue … [about the] patient and doctor – is also a basis for conceptualization. It is a difficult situation which leads to many complexities. p.196
 See Sacks, H. (1992) p.259 for a discussion of this passage by Frieda Fromm-Reichman.
 The range of recollections can be extended to include jokes, reminiscences, etc.
 Dr. Barbara Korsch at Children’s Hospital of Los Angeles kindly provided the author with tape-recorded interviews between doctors and parents with their children. Dr. Barbara Korsch was principal investigator in a variety of studies dealing with doctor-patient communication. Krakowski, J. (1968) reported his analysis of a mother/child relationship.
 See Adato, A. (1980). In personal communication, Adato expressed that “conversants routinely draw from the immediate occasion such events and features of it which provide for the sense of topicality, of what they're talking about”. Adato shows how topics, similar to a mother’s attentiveness to a silence, are intimately linked to the local setting – within the flow of natural conversation. His data consisted of a series of tape-recorded lunchroom conversations at a white-collar business.
 He neither prescribed nor restricted a code of conduct for the therapist. Here is another similarity between how Hellmuth Kaiser and Carl Rogers may have practiced therapy.
 The formulation: “be yourself,” has a familiar ring in contemporary psychotherapy, particularly humanistic psychology. What is of interest is not merely the similarity between a variety of formulations, but the path that is taken in arriving at each of the formulations.
 The relationship between the two (or more) attitudes is not fixed: They may or may not be contrasting; They may or may not be in conflict with one another; They may or may not derive from one another, etc. Their interrelationship may never be clear. That understanding is irrelevant to a course of treatment.
 Kaiser, in Fierman (1965), made this observation about “G…” The quoted remark refers to behavior of the therapist. The quote is interesting because it suggests that while Kaiser did not address clinical materials from the perspective employed in this paper, he seems to have made observations of his own clinical experience similar to those discussed in this paper: smiling and, in a special way, not being aware of smiling.
 Sartre (1956) confronted a similar question in his philosophical investigations that resembles the paradox of the smile. However, Sartre was occupied with investigations of perceptions of reality. He was interested in the question of what the individual simultaneously knows and does not know as an aspect of social, political and moral consciousness. His position was that when the individual does not know what he should know, this was an instance of “bad faith” (self-deception). Sartre does not examine behavior in the course of an interactive process. His discussion of a paradox, though similar in its wording to the issues under discussion in this paper, does not apply. For a psychological examination of this issue, see Shapiro (2000) and his treatment of “self-deception.”
 By depicting himself as a bully, the patient seems to disregard the negative view he projects of himself. This is a common feature in a patient’s interaction with his therapist. Nevertheless, there may be broader sociological and psychological implications to exposing oneself in an unfavorable light and not being aware of it. The patient’s attention is focused towards convincing the therapist of the correctness of his position and he is not concerned about the possibility of making unfavorable impressions. The following illustration is offered to point to a similarity of this phenomenon to materials totally unrelated in every other respect.
In field observations by Krakowski, J. (1972), of behaviors in a mental retardation facility, one of the residents complained about another resident: “Tommy said ‘fuck’.” The resident did not avoid the use of the expletive, even when that usage could reflect badly on him. The resident used the word without regard that in his own action, by repeating the socially offensive word, he was committing the same transgression as the offending resident. Similarly, the patient in the present example did not avoid the possibility of making a negative impression in reporting his bully-like behavior.
 There is no reason to assume that the same dynamics that operate to conceal his self-awareness of the existence of the smile during the course of delivering his narrative were not also operative in the course of the fight. If he did smile during the fight, he would not be aware of his smile unless it was pointed out by someone else.
Natural language philosophers and linguists examine utterances in isolation of the interactive context. For example, J. L. Austin’s (1962) conception of words-as-actions “performatives,” he recognizes the significance of a social environment but only in so far as others are witnesses. Harvey Sacks (1992) treats action exclusively as having interactive consequences. Duplicity, as it is treated within this paper, is examined as a phenomenon within an interactive context.
 There are classes of behaviors that result from a reaction to a process of self-monitoring of one’s own thoughts. Within a clinical setting, a patient may react to his own thoughts, impressions, behaviors, and attitudes in the same way that he reacts to the behaviors of the therapist. When the patient reacts to himself, he reacts to his immediately preceding thoughts as if they were expression by another (not necessarily that of the therapist). For example, an insanely jealous teen-ager bitterly complained about his girlfriend. He was convinced that she is imminently on the verge of committing infidelity: “She has done it t-hhh-hhhe-hhhhe-wice already.” He laughs uncontrollably as he says these words. He recognizes in that instant in which he was making a strong case for her frequent transgressions, that he has fudged in his calculation: she had “cheated” on her previous boyfriend, which made their present relationship with one another possible. He discovers while talking to the therapist that this prior transgression should not have counted against her. He identified her incorrectly as a frequent offender. He realizes that he was prejudicial in concluding that she was a frequent offender (he begins his statement that she had committed infidelity three times already). His conclusion that he was justified in his feelings of jealousy turns out, as he hears himself, to be based on a miscalculation. His laughter in the midst of his own talk was his reaction to the sudden awareness that his jealousy was objectively unfounded. The therapist’s presence was the catalyst.
 Roy Schafer (1992) makes a distinction between clinical and theoretical analysis: “… there is all the difference in the world between clinical and applied psychoanalysis for, in applied analysis, ‘there is no patient to talk back.’” p.174 This remark recognizes the potency of an interactive process.
 David Shapiro (1989) has discussed the mechanism by which neurosis is self-preserving.
 Carl Rogers (1961) p.32 used the term “cure” as well, although he later replaced it with “personal growth.”
 Pharmacologists search for thresholds that fall short of inducing a vegetative state – particularly in institutional settings.
 By definition, any non-directive therapy will have as an ideal not to interfere. Practical remedies are implicitly regarded as exempt. In a Kaiserian approach, practical remedies to problems fall outside of a concern with the anomalous shape of a patient’s behaviors. The therapist’s communicative attitude does not encourage a collaborative relationship between therapist and patient where the therapist is engaged in practical problem solving.
 Jerry Rochman (1999), a psychologist who has for many years explored various aspects of Kaiser’s thoughts, uses the phrase: “relaxed attention.” This phrase captures the methodological ideal in anthropology of the non-participant observer. In that capacity the therapist is unobtrusive, while at the same time an observer. His discussion stimulated some of the thoughts in this paper.
 At the instant the therapist sees the smile, he is empathic to the patient’s attitude that produced the smile and not just the smile. Understanding, in this context, does not mean that the therapist needs to know the source of the smile.
 The terms “therapist” for “counselor,” and “patient” for “client” are treated here interchangeably without intending any disrespect for the reasons that those terms are used in their original context.
 Heisenberg’s Uncertainty Principle suggests that the measuring instrument may itself affect the resulting measurement. Had the question in this fragment not been posed by the therapist, the thoughts as they are expressed by the patient may not have occurred to the patient. The character of excessive formality in the patient’s response may be the byproduct of responding to an unexpected question and not the anticipation of talking to his parents. This reasoning argues against this example as an instance of duplicity. Rogers, C. (1942) p.137, comments on this very problem of the question he asks in this fragment. A Kaiserian therapist rarely asks such questions and Rogers asks such questions very infrequently. The discussions of materials in this paper are designed to illustrate, not to prove.
 In an annotative comment to this fragment, Rogers, C. (1942) is critical that the therapist was distracted from an ideal theoretical frame of reference as to how the interview should have been conducted. He singles out the same lines of text in this fragment as an instance in which the therapist had failed to adhere to the agenda of getting at the patient’s feelings: “Only once is there any evidence that the counselor changes the train of Paul’s [the client’s] thought and feeling…to which Paul replies, ‘About this?’ showing that he has been thinking about something else.” p.137
The comment in the annotation indicates that if he had had control over what he said in the interview, he would not have made this remark. To the extent that the therapist made a remark that he wished he had not made, this might suggest that in this instance, at least, the therapist had felt compelled to make the remark.
 Fierman, in personal communication, expressed that Kaiser, towards the end of his career, dispensed with all concerns of duplicity and stressed instead a relationship of “communicative intimacy.” Communicative intimacy is discussed in his book The Therapist is the Therapy, Fierman, L. (1997). The therapist’s reaction to the patient’s duplicity, as it has been presented in this paper is not an end in itself. It is only one component in the overall framework of Kaiser’s therapeutic technique. In that overall framework, the therapist reacts to the patient in a seamless, effortless and non-directive manner. There is at least one other component that is not examined in this paper: the patient’s reactions to the therapist’s reaction. In the reaction of the patient to the therapist, it would seem that there is nothing in the therapist’s behavior that would be unavailable to the patient; there is nothing the therapist needs to do other than be himself. Examining duplicity and the therapist’s communicative attitude is only a first step. A more detailed discussion lies outside the scope of this paper
 The ideal therapeutic dynamic takes place when the therapist reacts to the patient’s duplicity and the patient reacts to the therapist’s reaction to his duplicity [See footnote 39]. The Rogers’ excerpt may arguably contain an example of the patient’s reaction to the therapist’s reaction: his laughter in line 4. The claim that the laughter serves such a function is from an analytic point of view, only tentative: It requires an analysis of laughter in the course of communication.
 See in particular Shapiro’s (1989) Psychotherapy of Neurotic Character for his discussion about the therapist’s experience in psychotherapy.