Q: I feel unprepared to make a proper suicide assessment with my clients. I’m nervous that I’ll neglect to ask, or the client won’t tell me, something vital to making the right clinical decision. Can you recommend an objective measure for reliably determining suicidality?
A: Suicide assessment is a high-stakes process infused with uncertainty, so your desire to find an assessment instrument to help with your decision-making is understandable. However, even the best scales can be unreliable when they’re completed in the midst of an emotional crisis. Thus, rather than outsourcing your decision-making to an instrument, I recommend that you learn how to conduct a conversational evaluation that builds on your therapeutic skills. While most clinicians already know to ask whether a client has an intent to die, a suicide plan, or access to a means for carrying it out, it’s important to go beyond simply posing these questions to get a fuller picture of the client’s risk of suicide.
Effective suicide assessments are built on a foundation of empathic connection. When clients feel heard, understood, and respected, they’re likelier to let down their guard and explore sensitive topics. In broaching such topics, the best way to protect them from feeling grilled is to intersperse your questions with empathic statements, such as “Sometimes your obligations feel impossible to meet,” or “It sounds exhausting to have to fend off intrusive thoughts of taking your life all the time.”
To help guide your assessment dialogue, my colleague, psychiatrist Len Gralnik, and I have identified four broad categories of inquiry:
Disruptions and demands—such as the loss of a relationship or social and financial status, overwhelming expectations and obligations, legal entanglements, and instances of abuse, bullying, or other traumas.
Suffering—from emotional problems (depression, mania, anxiety, anger, obsessive thinking), psychiatric problems (hallucinations and delusions), social pain (conflicted identity, shame), sleep problems, and physical problems (pain and illness).
Troubling behaviors—those that increase the danger of a client’s situation, such as withdrawing from activities and other people, engaging in substance abuse or disordered eating, acting impulsively or compulsively, and harming oneself or others.
Desperation—which encompasses many of the most urgent indicators for concern, such as hopelessness, an intense desire for relief, an intent to die, a plan for making a suicide attempt, a history of making one or more attempts, or making preparations for a future attempt.
To get a deeper sense of whether clients are in imminent danger of making a suicide attempt, you must obtain a clear view not only of the likelihood that they’ll act on their desperation, but also of their resources for making it through the crisis. To this end, you’ll want to explore intra- and interpersonal sources of resilience, protective beliefs, exceptions to problems, past successes, current skills, and effective strategies for dealing with stressors. For example, I once saw a former college football player whose game-hardened ability to keep moving forward, regardless of injuries and pain, served as a source of resilience when he felt like succumbing to suicidal thoughts. Also, some of my deeply religious clients have been protected by their faith’s prohibitions against suicide. I can almost always find some degree of variation in my clients’ desperation. If there are times when they feel more overwhelmed and depressed, that means there are times when they feel less so.
However, when you make note of your clients’ resources, take care not to appear overly impressed by their resilience or the support that’s available to them. To them, life is hopeless, so straightforward optimism on your part will likely be slapped away as irritating naivety. Instead, it’s helpful to adopt a casual manner when making resource-based inquiries and noting any positive discoveries. For example, you could say to my client who’d played football, “So when you were playing college ball, you didn’t let the pain slow you down? Have you always had that kind of strength and determination, or was it something you learned? How’s that coming into play these days?”
Some clinicians routinely use boilerplate no-harm or no-suicide contracts, hoping to secure a troubled client’s commitment to live and lessen their own legal exposure if the client were to end up completing suicide. Research has shown, however, that signing such contracts doesn’t afford the client any added protection; and when sued, clinicians who use contracts don’t fare any better in the courtroom.
Instead of no-harm or no-suicide contracts, I prefer working with clients to construct a uniquely relevant safety plan, a resource-based to-do list that identifies protective steps the client and his or her significant others are willing and able to undertake.
In developing the safety plan together, first decide how the client and significant others can restrict access to all possible means for attempting suicide. You can also explore reasonable alternatives to troubling behaviors for coping with distress and identify safe havens the client could access for a limited time if necessary. Write down the contact information for anyone who could offer a safe haven or other forms of support.
I once consulted on a case involving a young suicidal woman, Michelle, who had persistent thoughts of jumping off the balcony of her 11th-story apartment. Although her parents weren’t available to help, Michelle said she had a good friend, Vanessa, who lived on the ground floor of the same building. I arranged for Vanessa to come into our session, and the three of us worked out details of a safety plan. We decided that whenever the thoughts of jumping ramped up, Michelle would first go to her walk-in closet, which she considered a safe haven. Once there, she’d meditate and, if necessary, call the numbers of family, friends, and professional resources that we wrote down. If these measures didn’t feel safe enough, she’d take the elevator down to Vanessa’s, and—with the key that Vanessa said she’d give her once they got home—let herself in. Michelle didn’t consider or worry about any other methods of dying, so the measures necessary for keeping her relatively safe were fairly straightforward.
A safety plan is designed as a temporary measure to get suicidal clients through distressing times, so you need to make sure the plan is reasonable and doable. A plan that’s too elaborate or demanding isn’t safe. In addition to significant others, you and the client should consider enlisting his or her work supervisors or school administrators to alter the client’s schedule, reduce his or her workload, or grant a leave of absence. Also, determine whether the client would consider initiating, resuming, or continuing relevant therapy or treatment. In addition to generating a list of personal and professional contacts the client could call if necessary, identify emergency contacts such as crisis lines and nearby hospitals. Once the safety plan is complete, make a copy for your file and give the original to the client.
If the client appears to be at imminent risk of making a suicide attempt and a safety plan doesn’t seem feasible or sufficient to keep him or her safe, then you’ll need to arrange transportation to a psychiatric receiving facility for evaluation and possible involuntary admission. But never make this choice simply to be on the safe side. Sending someone to the hospital who’s depressed but not suicidal, for example, may alleviate your immediate anxiety, but it may cause the client to avoid seeking out mental health treatment in the future.
Arrive at your safety decision by piecing together all the information you gather throughout the assessment: what the client tells you, what you empathically glean, and what you know from the professional literature about risks and resources. Whenever possible, consult with a colleague or supervisor, so you can compare your perspectives.
Once you make a decision, give yourself the opportunity to take a second look at it, along with the data informing it. If, upon considering everything a second time, you come to the same conclusion, then you can proceed with added confidence. If you end up with second thoughts, listen to your doubts and use them to prompt further information gathering.
It isn’t unusual for me during an assessment to change my mind several times about whether a safety plan can be a viable option for keeping a client alive. Much of what Michelle told me—about her depression, thoughts about jumping, absence of family—pointed to hospitalization as the best choice for keeping her safe. But glimmers of hope kept appearing, so I kept asking questions, and together we finally determined that she had the necessary resources to stay safe—and we were right. She told me much later, when the crisis had passed, that she’d pinned up her safety plan inside her walk-in closet and would go in there and read it as a source of reassurance and inspiration.
Ultimately, suicide assessments are inherently anxiety-provoking and emotionally taxing, even when they go well and the client can safely negotiate harrowing desires, thoughts, and circumstances. Following an assessment, it helps to secure time with colleagues to talk through how the client presented, what you were able to discover, what you decided, how the client responded to the process as a whole, and what you were experiencing throughout the process. Taking care of yourself in this way will help you feel better prepared the next time.
Douglas Flemons, PhD, is Professor of Family Therapy and Clinical Professor of Family Medicine at Nova Southeastern University. He’s coauthor of Relational Suicide Assessment, author of Of One Mind, and coeditor of Quickies: The Handbook of Brief Sex Therapy. He offers workshops on suicide assessment, hypnosis, and brief therapy. Contact: email@example.com.
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Q: I’ve taken yoga classes for several years and know there are many physical, mental, and emotional benefits associated with the practice. How can I use yoga techniques to enhance my work as a therapist?
A:You can offer your clients many yoga-based practices to help them focus, relax, and access their feelings more readily during the session, as well as self-regulate at home. As you may know, the physical postures, known as asanas, are only one aspect of traditional yoga practice. A variety of no-mat yoga practices and rituals can help quiet mental chatter, reduce bodily tension, and promote a heightened awareness of oneself and one’s surroundings. All these techniques are perfectly suited to the consultation room.
The work of therapy can’t begin in earnest if the client’s mind is racing or fogged by depression at the beginning of the session, or if tension is so great that bodily awareness is lost. Offering a simple yoga practice as a portal into the session can enable your client to experience a shift in attentiveness and mood. Having moved into a state of heightened awareness, she or he may then be able to bring newfound clarity of mind to the issues looming throughout the session.
Carol, a woman in her mid-forties with a history of trauma and bulimia, was referred to me for yoga therapy by her psychotherapist. She entered our first session in a highly agitated state. Her shoulders were tight and drawn up toward her ears, and her breathing was rapid and shallow. She was fairly new to yoga and nervous about our work together. After two rounds of a tense-and-release exercise and a brief check-in, I guided Carol in these simple, yoga-based practices: mudra, the use of a hand gesture; pranayama, a simple yoga breath; bhavana, locating an image of sanctuary or peace; mantra, a soothing universal tone; and kriya, a cleansing breath. This series of practices, which took under two minutes, respected Carol’s revved-up state while helping her self-regulate.
Tense and release. To begin, I said to Carol in a calm voice, “Take a moment to tighten as many muscles as you can. Draw the shoulders up to the ears, squinch up your face, make fists with your hands, and sustain your breath. Compress all the getting-here-on-time anxieties and all the judgments you have into a little ball, and place it at the back of your neck. Squeeze the ball, and then let it roll down your back as you let the breath go. Beautiful! Let’s do that again. Inhale and tighten as many muscles as you can. Squeeze whatever is keeping your heart and mind from being completely open. Squeeze, squeeze, squeeze. Now, let it all go . . . beautiful!
Carol was visibly more relaxed after this exercise. Although her breath remained shallow, her face was softer and her eyes more focused.
The use of image. At this point, Carol agreed to try a simple practice we could do in our chairs to bring her current state of mind into balance. I asked her to think of a soothing image. “It could be a place,” I prompted, “real or imagined, where you’re relaxed and at ease. Or maybe,” I said, “a face comes to mind that makes you feel peaceful. It could be a human friend, a precious four-legged friend, or even a deity.”
Carol closed her eyes. After a few moments, I asked her to raise her finger if she’d found an image. When she’d located an image and had opened her eyes, I asked if she’d feel comfortable sharing her image with me. She said she saw her favorite beach in Hawaii. (If your clients can’t find an image, you can ask them to simply think the word peace.)
Notice that as I guided Carol in forming an image, I didn’t use the word safe, as this might have triggered Carol’s mind to think of the opposite, putting her back in a position of fear and anxiety. I also didn’t suggest a specific image, but guided her to create her own. That way, she felt ownership of the image, and her sense of self-efficacy and empowerment was bolstered.
Arm movement, breath, and mudra. Because her breath was shallow and in her upper chest, I didn’t ask Carol to breathe deeply at this stage, since that might have been too difficult. Instead, I chose a breath practice to work with the short breaths she was already taking. I call this practice Stair Step, but it’s actually an ancient technique known in Sanskrit as Anuloma Krama. I demonstrated how to open her arms wide to the sides, raise them up over her head, and then interlace her fingers with her index fingers extended toward the ceiling. This hand position is a mudra.
Mudras engage many nerve endings that activate various regions of the brain. In addition, by asking her to raise her arms over her head, I helped her increase body sensation and body awareness, which is important because many trauma survivors feel unsafe in their bodies. They often say they feel as though they live from the neck up. At the end of the exercise, you’ll see how, through my cuing, I made use of her heightened body awareness to allow her to reoccupy her body safely without ever having to use the word safe.
As we began the practice, I invited Carol to close her eyes or, if that didn’t feel comfortable, to lower her gaze to the floor. I kept my eyes open, so I could see how she was breathing. As a clinician, you want to keep your eyes open while leading a practice, unless your client requests otherwise, so you can monitor the effect of the practice.
As she was lifting her arms, I instructed her to inhale little sips of breath through the nostrils, as though she were climbing a mountain with her breath. When she arrived at the top of the mountain, I cued her to pause and imagine the beautiful scene on the beach in Hawaii she’d chosen as her image—sky, waves, sand, everything. After just a heartbeat or two, I guided her to lower her arms to the side, knowing that from this final position, she’d let her breath out slowly on her own. “Beautiful,” I said.
Adding the mantra. We practiced the Stair Step exercise twice, and then I told Carol that we’d add the mantra so-hum, a soothing sound that I explained means “I am that” in Sanskrit. From my intake form, I already knew that Carol’s religious beliefs wouldn’t be in conflict with a simple, nondeity mantra in Sanskrit. Had this been otherwise, we might have used shalom, amen, or soob-hahn-all-ah to meet her religious beliefs as a Jew, a Christian, or a Muslim, respectively.
We practiced the Stair Step exercise three more times with the mantra. Using the sound helped her slow her breathing even more. Research has shown that mantras are effective because an extended exhalation stimulates the parasympathetic nervous system, relaxing the body. In addition, a soothing sound like so-hum or om deactivates the limbic brain, which is often hyperaroused in individuals with a history of trauma.
Body sensing. As we finished the practice, I invited Carol to sit with her eyes closed and observe the sensations in her arms, palms, and fingertips. “Sense deeply into your palms,” I said. “The mind is a time traveler, but the body is always present. Sensing that feeling in the palms is like having a window into the present moment.”
Notice that I didn’t ask her to feel the sensation in her body in a global way. A client with a history of trauma similar to Carol’s may carry a belief that it isn’t safe to live in her body, or that she’ll be overwhelmed with emotion if she lets herself feel her body. But when we’re specific in our cues to feel sensations in the palms or fingertips, for example—places where there are a lot of nerve endings—we give the client the gift of reoccupying the body in a manner that feels safe.
When we finished these simple exercises, I could see that Carol’s belly was expanding as she inhaled, meaning she was naturally breathing more deeply. Her exhalations came slowly, and her eye contact was steady as well. She said she felt relaxed and a little excited about how easy it had seemed to shift her mood. I told her that the image of the beach in Hawaii was on the altar of her heart, and that she could go back to it any time she felt stressed. She could add the Stair Step breath and the brief pause, for no more than four counts, at the top of the mountain. Since she liked the so-hum mantra, I invited her to use that whenever she felt agitated.
At this point, we rose to move to the yoga mat. However, if Carol were your client, you could begin the work of talk therapy with greater clarity and a deeper sense of connection between the two of you.
Amy Weintraub is the founder of the LifeForce Yoga Healing Institute, which offers trainings in the clinical application of yoga. She’s the author of Yoga Skills for Therapists and Yoga for Depression. Contact: email@example.com.
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Q: I’d like to organize a peer supervision group, but I’ve heard their failure rate is high. What do you recommend?
A: Peer supervision groups provide a welcome respite from the isolation of private practice and an informal, nonevaluative setting after years of formal supervision, particularly for young therapists. They offer valuable guidance on difficult cases and tough ethical dilemmas to therapists at any level of experience. And they’re free! However, as you note, many of them fail. In my experience, careful attention to the initial contract and the ongoing group process can make a huge difference in helping them sustain their membership and thrive.
Though they’re often called peer supervision groups, it would be more accurate to call them peer consultation groups. Members don’t have direct supervisory responsibility for one another’s cases: they simply offer suggestions, which members can accept or reject. They typically have four to six members who have approximately the same level of professional experience or share a specific area of interest. Members meet on a regular, usually biweekly, basis.
Group consultation, with or without a leader, offers advantages over individual consultation. It includes the possibility of multiple perspectives on the same problem and the reduction of clinicians’ shame about confusions and mistakes as they share similar stories about their struggles with difficult cases. Another benefit is peer interaction, which develops one’s professional sense of self. The hall-of-mirrors effect—seeing yourself as others see you—which is so potent in therapy groups, is a major component of the supervision group experience.
Nevertheless, despite the many benefits, it’s challenging to start and maintain a consultation group, particularly if it’s a leaderless one. They can fail to thrive or suffer from “task drift,” moving them away from discussing clinical material and into a form of therapy. It can be difficult to integrate new members and maintain clarity about the group’s own process. Presenting cases in supervision in any format poses obvious risks to one’s self-esteem, and group dynamics add additional risks: issues of power, competition, exposure, and shame can lead members to drop out. It’s especially challenging to manage group dynamics in leaderless groups, as it’s usually the leader’s role to remain aware of what’s happening within the group, and without a leader in charge, shame or fear of being judged may silence members.
The most successful leaderless groups seem to be those in which the group members find a balance between a focus on cognitive and emotional issues—talking about cases and about the feelings that arise when seeing clients—while consciously managing the functions that a designated leader would serve. These include protecting the group contract, setting and maintaining appropriate norms, and handling gatekeeping matters, such as bringing in new members.
A crucial component of maintaining an atmosphere of group safety is regular, dependable member attendance. Without this, a group will never feel like a place to take risks. Members need to be willing to bring up concerns about irregular attendance because, just as in a therapy group, member lateness and absences can indicate issues that need exploring. Chronic irregular attendance can be demoralizing and cause a group to fail. When it comes to group safety and cohesion, Woody Allen was right: 90 percent of supervision group success is about showing up.
A significant issue in any supervision group is shame and the reluctance to expose oneself. To make supervision groups feel safer, therapist David Altfeld developed a model of group consultation in which all group members simply share their emotional reactions and associations to a situation being discussed, instead of one person presenting a specific case issue and everyone else giving advice as resident “experts.” This procedure levels the playing field by not allowing members to compete for the best case analysis. It leaves room for highlighting emotional issues, countertransference reactions, and parallel process. Making everyone vulnerable in this manner avoids opportunities for excessive criticism (or its counterpart, excessive niceness) and encourages emotional sharing.
Another group consultation model, developed by Irish therapist Bobby Moore, focuses only on minimal case information, such as a patient’s age, length of time in therapy, and perhaps a little demographic information. Then the presenter talks about his or her thoughts, fantasies, feelings, and associations about the patient and the therapy. Group members then share their associations. Following that, the initial presenter is invited to share any further associations. Only at this point does the presenter give the facts of the case and the clinical dilemma. Finally, the group thinks together about what’s been discussed and what it indicates about the case. For those interested in the power of the collective unconscious, this is a fascinating process to experience.
To succeed, a consultation group must feel safe and useful to its members. Here are a few simple principles to follow:
Clarify the group structure. The group needs to agree on the frequency and length of meetings, which is best accomplished with a predictable schedule. The group needs to agree on its task and focus: is this group for any clinical issue or just for couples, or trauma, or group therapy? How much time will the group spend on “schmoozing,” and will there be one or more than one case presented each time? What will be the presentation format? While most groups use verbal presentation, some groups are now using videoclips—which makes the discussion much livelier.
Agree on membership issues. How many members will the group have, and how will new members be integrated? Once a group has formed, I believe that decisions about adding more members should be a group decision. While it may be tempting to accept a request from someone who wants to join the group, a total of six members seems to be the maximum number for each member to have enough opportunities for presentations.
Attend to the group process and dynamics. While groups should build in a “schmooze” or “check-in” time, there needs to be an agreed-upon limit to the socializing, so that the group doesn’t become a therapy group or a coffee klatch. Without a leader, the members themselves must monitor the group’s procedures and raise any important issues. Some groups do this ad hoc; others schedule a regular review meeting to evaluate how things are going.
Leaderless peer supervision groups can help clinicians at any stage further clinical learning and combat professional isolation. They’re likeliest to succeed when the group members have a clear working agreement, maintain regular attendance, and create an environment in which both emotional and cognitive learning occurs.
Eleanor Counselman, Ed.D., is a past president of the Northeastern Society for Group Psychotherapy and an assistant professor of psychiatry at Harvard Medical School. She’s published numerous articles on psychotherapy and has a private practice in Belmont, Massachusetts.
Q: One of my European colleagues is excited about “mentalization” and Mentalization-Based Treatment. What is it?
A: Mentalization refers to the mind’s innate capacity to make sense of social experiences and implicitly know how to respond to them. Think about the following examples. You arrive home and say, “Hi” as you open the door. Your partner says, “Hi” back. Without a second thought, you’re aware of the tension in his voice that suggests he’s had a hard day. Or after a meeting with an old friend, you experience an uneasy feeling. Reflecting on your time together, you realize that you’re feeling bad because your friend takes a superior attitude with you.
Mentalization enables us to understand the intention or purpose behind other people’s behavior from their tone of voice, facial expression, and body posture. Therefore, when someone comes toward us wearing a grimace and hunched shoulders, we “get” that he or she is upset and perhaps angry. We instinctively recognize that mental states—thoughts, feelings, beliefs, or attitudes—underlie almost all behaviors.
This concept was introduced into the clinical literature by Peter Fonagy of the Anna Freud Centre in London in the 1990s. In a series of papers, including “Thinking about Thinking” in 1991 and “Playing with Reality” with Mary Target in 1996, he explored the theory of mind’s central role in the development of a sense of self. Drawing on clinical studies of borderline personality disorder and violent behavior, he argued that the failure to read and get the implicit meaning of another’s actions led to the loss of impulse control, an unstable sense of self, and problematic relationships. In the last 20 years, the mentalization model of mind has gone from being an obscure aspect of Attachment Theory to the centerpiece of Mentalization-Based Treatment (MBT) for borderline personality disorder. It’s now being integrated into treatments for addiction, trauma, eating disorders, and other conditions. But how does it work?
While mentalization fosters an empathic awareness of the moods and mindsets of others, it also enables us to know what our own states of mind and body mean. Our brain–minds assemble information about the state of our body, the input of our senses, and our associative memories to grasp our own intentionality. We mentalize explicitly by reflecting on experiences, conscious narratives, and empathic communication with others. Our “social brains” have evolved over the eons to become highly specialized in “reading” others’ minds, and our own. Menninger Clinic psychologist and mentalization expert Jon Allen and colleagues believe that mentalization is at the heart of emotional and social intelligence, and is central to all interpersonal experience.
Fonagy asserts that mentalization represents the epitome of human cognitive evolution and is the foundation of all effective psychotherapy. In fact, research has shown that when people lose their ability to mentalize their experience—usually in the context of high affect and threats to emotional security—they have a hard time making sense of other people’s behavior and their own. They become reactive, impulsive, and self-centered, and lack perspective.
Fonagy’s early work examined the development of borderline personality disorder. He found that people who became borderline had fragile mentalizing capacities and were vulnerable to breakdown in close interpersonal situations. The research also revealed that these people had often grown up in families that inhibited mentalization skills. In abusive families, for instance, high levels of frightening feelings overwhelm and shut down children’s capacity to think about what’s happening. In addition, children may avoid reflecting on their parents’ intentions, since it could be terrifying to understand their confusing and, at times, hateful feelings toward them.
These findings dovetail with similar data generated by the Adult Attachment Interview, developed by psychological researcher Mary Main. She found that individuals who are able to reflect on their relationships with their parents with perspective and understanding were likelier to be secure in their attachments to others and have securely attached children.
Rather than being an entirely new form of treatment, mentalization-based therapy contributes to our understanding of what happens in many different approaches. Fonagy argues that achieving more stable and robust mentalization constitutes success in most treatments because it enables people to regulate their own moods more effectively and think coherently about themselves and what they want. By focusing on mentalization as a skill, therapists help clients understand more of the connection between how they feel, what they want, and how they act by themselves or with others.
Mentalization encourages a nonjudgmental attitude of curiosity, inquisitiveness, and open-mindedness toward the client’s subjectivity. Rather than assuming a role of expert, the therapist adopts a “not-knowing” stance, founded in the belief that we come to know what it’s like for another by inquiry, not by assumptions or formulations or by explaining clients to themselves. It’s a here-and-now, process-oriented approach. The therapist encourages the client to think about his or her experience, the goal being to learn to “think about feeling, and feel about thinking.” The therapist guides the client to step back and take perspective on their experience together in therapy: “Yes, that’s one possible meaning; what are others?” “How do you imagine it looks from my point of view?” He or she listens to the client’s narrative and seeks to explore the aspects that are being neglected.
Some critics have wondered what’s gained in using the term mentalization as opposed to empathy, psychological mindedness or affect awareness. Some find Daniel Siegel’s idea of mindsight a friendlier term referring to many of the same functions. But in my own practice, a focus on mentalization has deepened my understanding of the balance between affect and cognition and the need to integrate these aspects of experience. Of course, we all know, theoretically, that the therapeutic connection is at the heart of all good therapy, but understanding the moment-to-moment processes of mentalization can deepen a therapist’s understanding of just how shifts in the relationship can lead to lasting therapeutic change.
Steven Krugman, Ph.D., is a psychotherapist in Boston. He teaches about Attachment Theory and interpersonal neuroscience, and is on the faculty of the Psychoanalytic Family and Couples Institute of New England. Contact: email@example.com. Tell us what you think about this article by e-mail at firstname.lastname@example.org.
Q: I know that getting immediate, nonverbal feedback from clients is essential to knowing how they’re responding in a session. How can I increase my sensitivity to this?
A: Being sensitive to a client’s nonverbal shifts in facial expression, posture, voice tone, and other areas is certainly important in establishing and maintaining the therapeutic relationship, which much research shows is essential for successful therapy. However, noticing nonverbal shifts isn’t enough; it’s important to know what those nonverbal shifts are related to and what they mean. To do this, you need to be active in eliciting responses, both verbally and nonverbally.
For instance, if clients verbally assent to what you’re saying while nonverbally disagreeing, it’s important to pick this up immediately, so that you can address the incongruence. If you want to detect the nonverbal signs of agreement, disagreement, and ambivalence, you can say, “I’d like to ask you to do something that may seem a bit strange, but it can be useful to us in working together. I want you to think of something that you fully agree with; it doesn’t matter what it is, and don’t tell me what it is, just nod when you’ve thought of something.” Then notice any nonverbal shifts. The client’s attention will be focused on the task, while yours is on the response to it.
Some clients will immediately think of something, and respond quickly, often before they nod. Others may take a little longer as they go through a brief search process before deciding on something and nodding. You want to notice what’s different compared to their state before you gave them the instruction, and the speed of their response is useful information. If you want to be more covert, you can say, “So your name is Fred Freed, is that right?” and notice his response. If you don’t notice anything, you can ask about something else that you’re pretty sure he’ll agree with, until you do detect the nonverbal response.
Clients are likely to be aware of smiles, nods, frowns, and other facial expressions with commonly accepted meanings. Since these can be faked, they aren’t reliable indicators of unconscious signaling. Clients are much less likely to be aware of small shifts in breathing, posture, head position, and so forth, so these indicators are much more reliable. Many responses to positive states can be categorized as parasympathetic: relaxation, movement, leaning forward slightly, pinker skin color, slower breathing and heart rate. Other responses will be individual to the client, and may include slight head tilts or movements, change in direction of the gaze, and small movements of fingers or hands.
Then you can say, “Thanks, now think of something that you completely disagree with. Again it doesn’t matter what it is, and don’t tell me what it is, just nod when you’ve thought of something.” The contrast between the response to this and the previous instruction will highlight what was different in the responses. Many responses to negative states can be categorized as sympathetic ones: tension, stillness, moving backward slightly, whiter skin color, faster breathing and heart rate. But many other shifts will be individual to a particular client. One client showed a slightly open mouth in agreement, but a closed one in disagreement; another looked up for agreement and down for disagreement.
If you don’t detect any clear shifts, you can ask the client to think about agreement again, and the contrast will make it easier for you to notice more. Finally, you can say, “Now think of something you’re uncertain about,” and, typically, you’ll see a mixture of what you noticed for agreement and disagreement. By asking specific questions like these, you can discover what nonverbal reactions are involved when this particular client agrees, disagrees, or is uncertain. You can use the same kind of inquiry about anything else that you think is relevant to your therapy, dividing it into positive, negative, and neutral: like/dislike, curious/bored, commitment to carrying out a plan, and so on.
You can do many other things to increase your sensitivity, all of which involve shifting your attention. Many therapists need to pay more attention to the nonverbal expressive music of the clients’ voices, rather than the content of what they’re saying. If a therapist looks aside while clients are talking, it can be easier to notice tonal and tempo shifts. But if a therapist looks down while they’re talking, and then looks up only as they finish, most of the nonverbal responses have already occurred, and are thus impossible to notice.
It’s easier to detect your clients’ subtle nonverbal changes in position and movement with your peripheral vision than with central vision. This is why soft defocusing and becoming more aware of peripheral vision is taught in all the Asian martial arts. If you’re seated opposite your client, as most therapists are taught, most of the client’s body will not be in your peripheral field of vision. If you sit next to your client at a 45-degree angle, so that you’re facing in more or less the same direction—as Fritz Perls and Virginia Satir did—most of your client’s body will be in your peripheral vision, automatically increasing your sensitivity.
There are many other advantages to sitting next to clients, often involving your nonverbal signals and their impact on clients. Facing more or less in the same direction has nonverbal implications of alliance and support, working together toward a joint outcome—in contrast to sitting opposite, which has implications of opposition or confrontation.
When clients remember the past, or think about the future, they often look at images that are directly in front of them. If you’re sitting in front of them, you may be in the same location as these images, which can be confusing.
Assuming that you’re facing in much the same direction, would you put the client’s chair on your left side or your right? In most right-handed people, the right brain is more sensitive to nonverbal emotional expression. Since the right brain receives visual information from the left visual field, you’ll automatically be much more sensitive to the signals of your clients’ emotional states when they’re sitting to your left. The right brain detects threat faster, so if you’re working with potentially angry or dangerous clients, that’s another reason to seat them on your left.
The right brain expresses emotion more fully than the left brain, primarily through the movements of the left hand. Gesturing toward the client with your left hand implies an emotional connection, another reason to seat most clients on your left side. (If you or your client is left-handed, these generalizations may need to be adjusted. You can ask your clients whether they are right- or left-handed, or have them sign something and notice which hand they use.)
Sitting next to clients makes it easy to touch them spontaneously and naturally with your left hand, without leaning forward awkwardly or leaving your chair. Although many therapists are still taught that any touch is inappropriate or even unethical, it’s an effective nonverbal way to elicit responses. Satir, one of the greatest therapists who ever lived, said: “If I couldn’t have the energy that comes out with touch, I’m certain that I could not have the kind of really good results that I have.” If you’re sitting opposite clients, or behind a desk, it’s much more difficult to express this kind of simple human connection.
Experiments have found that when a sales or service person touches customers lightly and momentarily on the upper arm (one second or less), it substantially increases the purchases customers make in a store, the tips they give to waiters and waitresses, the evaluations of their shopping or dining experience, and the likelihood that they’ll return. A simple touch or two can work wonders for your relationship with your clients. If a client responds aversively to a touch, it could mean that your touch was awkward or incongruent, or that the client has significant issues with touch, or many other possibilities—all important to know about and address. Like most people, many therapists shackle themselves by worrying about how a client might respond, rather than trying something and finding out how it works. You can always apologize, and any response can be utilized.
Touch has many other uses. If you want to interrupt clients because what they’re doing isn’t useful, a touch can gently get their attention and distract them, as you offer them a new direction. If clients start to become angry, a light touch on the arm can instantly communicate alliance, safety, acceptance, and that you aren’t the target of their anger. If you want clients to pause and savor a newly emerging feeling or change in understanding or attitude, a touch on the forearm can amplify your request, “I’d like you to pause, and stay with what’s going on right now, so that you can experience it even more fully.”
When clients talk, they often gesture in space with one or both hands. If you’re sitting next to them, it’s easy to gesture in the same way and in much the same locations in space, giving clients an unconscious sense that you’ve really entered their world and fully understand their experience. If you don’t think this is important, try gesturing in ways different from what clients do and watch them become confused, tense, or withdrawn.
Sitting next to clients provides opportunities for the therapist to modify clients’ gestures to support changes in their experience. For instance, often clients gesture with one hand, while the other hand is motionless or gestures in a different way. Perls often asked clients to repeat the words, but to switch any gestures to the opposite side of the body, to engage the other brain hemisphere and facilitate integration between the verbal and nonverbal states. When this instruction is given while gesturing in clients’ personal space, it becomes even more compelling. Sitting opposite clients makes it difficult to make use of gestures in this way.
Without a video, it’s only possible in a short article like this to offer some general principles and ideas to try; however, I have an article describing the exquisite nonverbal gestures seen in a three-minute video clip of an interview with Diana Fosha. You can find both the article and the video clip at http://realpeoplepress.com/blog/nonverbal-expressiveness-the-key-to-relationship-and-change.
These are just a few aspects of the nonverbal interactions that you have with your clients—something usually far more important than the words you exchange or the content being discussed. There are many, many ways to become aware of how you interact with a client, and what turns the interactions into a dance or a wrestling match. Continuing to discover and explore these choices can make your work ever more sensitive, subtle, and effortless, as well as more interesting and enjoyable.
Steve Andreas, M.A., has been learning, teaching, and developing brief therapy methods for more than 45 years. His books include Virginia Satir: The Patterns of Her Magic; Transforming Your Self; and Transforming Negative Self-Talk. Tell us what you think about this article by e-mail at email@example.com, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.
Q: I know that the first session with new clients is crucial, especially when doing brief therapy. How can I make the most of it?
A: Like it or not, many of us are brief therapists by default. Stats tell us that clients go to an average of five to eight therapy sessions, but most of them go only to one, making it essential that we hit the ground running.
We all know the essential tasks of the first session in any kind of therapy: building rapport and a sense of collaboration, assessing and diagnosing, and formulating and offering a preliminary treatment plan. The tasks in brief therapy aren’t different, but they’re done in less time–meaning that therapists need to get to work immediately, and there’s little leeway for mistakes.
I find it useful to think of the first session the way a family physician might when a client shows up with an ailment. Basically, there are four goals to meet: getting on the same page, changing the emotional climate, clarifying the link between problems and personality, and offering a clear treatment plan–and if you miss any one of them, the client probably won’t return.
Getting on the Same Page
It’s useful to set the stage for brief therapy by letting clients know a little about your approach during the first contact–that you think brief, that you focus more on the present than the past, and that you give behavioral homework. You may tell them a little about your experience to convey a sense of your competence. Once they come to the session, like any therapist, you help them feel welcomed and safe. You can do this by listening carefully to their story and being empathic, subtly mirroring their body position or language to help foster rapport, and clarifying their expectations, either to reinforce them or to suggest alternatives.
But you can’t just listen for 50 minutes and then thank them for coming, take out your appointment book, and say, “Same time next week?” Not in the age of Dr. Phil. You must shape the process by offering direction and leadership, not just responses. This gives clients the crucial sense that you know what you’re doing and where you’re going with them.
However, the most important part of getting off on the right foot is what I call “tracking the process like a bloodhound.” This is where it’s easy to get lazy and lose focus. Clients instinctively want to talk content–to dig through their pile of stories and sort through the heap of facts. Of course, to some extent, that’s important, but you want to focus on what you see that clients usually don’t: what’s happening moment-to-moment in the room. Whether you make a comment or an interpretation or provide education, you need to watch closely how the client responds. Make sure you notice the nod of the head or other indicators of solid agreement. If you hear a “Yes, but . . .” or a lukewarm “That makes sense,” or observe eyes glazing over or a frown, don’t move ahead. Stop and address the problem that’s right there in the room: “Hmmm, you’re making a face. It seems like you may see it differently.”
Gently clarify your thinking, connect your thoughts to the clients’ most pressing concern, and make sure they’re in sync with you throughout the session. If they are and you can offer a clear treatment plan, you’re off to a good start. But if not, they’ll balk or seem uncertain about setting up another appointment. Then and there, you need to realize that, somewhere along the line, you fell out of step.
Changing the Emotional Climate
In a first session, clients are expecting something for their time and money: when they walk out, they want to feel differently from how they felt when they walked in. This is what I call changing the emotional climate. Simply listening and being empathic, allowing clients to vent, goes a long way toward accomplishing this. So does education. Talking to clients about the brain physiology of anxiety, for example, or typical family patterns can help normalize their distress and place it in a larger, fixable context. This is what your family doc does when she tells you that you have an infection or that your rash is simple contact dermatitis caused by the new cream you put on your face. You feel better having a label, an explanation, and a palpable sense of your physician’s educated concern.
In brief therapy, though, you need to ramp it up experientially. One of the most effective ways of changing the emotional climate is, again, zeroing in on the ongoing process with the client. You want to pay extremely close attention to the nonverbal communication, to tap the subtle feelings that are just below the surface. When Sara looks hurt, stop the story and focus: “Hold on, Sara, what just happened? You’re looking sad.” If you say this gently, with real sincerity, Sara may be able to drop her defenses and actually begin to tear up or cry. This open and shared vulnerability will help her emotionally bond with you. You can also do this by asking directly about these often softer and less obvious emotions: “What causes you to feel sad? What worries you the most?” Or ask about positive feelings to offset all the focus on negative ones: “When do you feel your best? What are you most proud of?” By asking, you move to a different level in your relationship with a client and change the climate in the room. Even if Sara seems to push your questions away, you’re still letting her know that you’re noticing how she feels and that this is a safe place to talk about difficult things when she’s ready.
While these points may seem fundamental to being a therapist, I’m always surprised when I see clinicians failing to create this powerful shift. They get too caught up in gathering history for assessment to notice these emotional subtleties, or they rationalize that it’s too soon to tap them. But that’s a mistake.
Linking Problems to Personality
The first question I always ask myself is: What keeps this person from solving this problem on his own? Sometimes it’s because clients have situational stress: they just got fired from their job, they have a medical crisis, their kid got busted for drugs. Normally, they can cope, but now there’s just too much on their plate. They need support and help to be able to zero in on the problem. Other times, it’s a matter of skill or lack of it: they have continual financial problems because they really don’t know how to set up a budget, or can’t talk with their partner without triggering conflict or disengagement. Once you help them understand and implement a budget or master the keys to good communication, the problem begins to fade.
Other problems persist, not because they’re rooted in stress or lack of skill, but are intrinsically linked to their personality and coping style. I think of this from the Buddhist standpoint: How you do anything is how you do everything. In fact, this is where some clients are stuck. While they’re worried about the what–the content of their problems–the real source and solution to their current problem, and many of the problems in their lives, lies in the how, their overall response to problems. This is what I call their core dynamic–an expression of their primary childhood ways of coping, such as accommodation, anger, or withdrawal. While these ways may have helped them survive the challenges of their early environment, now, like outdated software, they’re no longer helping them negotiate the more-complex demands of an adult world.
To move out of the 10-year-old’s perspective and better handle the problems in their lives, they need to update their inner software. More traditional approaches might track this down by a long march through the past, but in a brief approach, you can tackle it in the first session by asking how they concretely and specifically cope with current problems on the job or at home. Of course, you may even detect their coping style during the session itself, through their responses to you.
Once I’ve defined their coping style, I often try to link it to their current problem, helping them see the latest manifestation of the same outmoded response. By doing that, I set the stage for their attempt to challenge their early wiring: instead of being good and accommodating, as they’ve always done, the might push back and say what they need; or, instead of spraying anger around the room, they might self-regulate and use their anger as information. I let them know that they can update the software, which will not only fix their current problem, but prevent future ones.
This focus on defining, understanding, and challenging the core dynamic is empowering for clients. The message is that you can help them map out new ways of taking acceptable risks, breaking old patterns, and acting more like the adult they are than the 10-year-old they often feel like.
Offering a Clear Treatment Plan
Finally, like the physician, you need to leave clients with a clear set of next steps. If you decide the client is stuck because of situational stress, talk about ways of navigating this challenge in the scope of their broader lives. If it’s about coping skills, map out what skills you feel would be important for them to learn. If it’s about their core dynamic and ineffective approaches to problems, or a combination of all of the above, let them know what you’re thinking and what they concretely need to do.
Then, as always, track the process and see what happens next. Does this make sense to them? Do they agree? Do they understand how this is all related to their presenting concern? If there’s a sincere and congruent yes, you may give them concrete behavioral homework to help develop new skills or reduce their stress. If there’s hesitation, ambivalence, or accommodation, stop, clarify, or ask questions until you’re clear about what’s going on. Just remember that their resistance isn’t the problem, but a source of valuable, additional information about what the solution might be. As in any other phase of psychotherapy, it’s hard to go wrong if you bear in mind the clinician’s most useful mantra: track the process like a bloodhound!
Robert Taibbi, L.C.S.W., trains nationally and is the author of more than 200 articles and five books, including the forthcoming Therapy Boot Camp: Brief, Action-Oriented Approaches to Anxiety, Anger & Depression. Contact: firstname.lastname@example.org. Tell us what you think about this article by e-mail at email@example.com, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.
By Eleanor Counselman
Q: I’d like to learn more about therapy groups. Can you explain their therapeutic value and what skills are required to run them that are different from those of an individual therapist?
A: After many years as a group therapist, the main distinction I see between individual and group work is that clients tend to talk about relationship problems in individual therapy, whereas they inevitably exhibit them in group therapy. In a group context, a therapist can more easily and directly see what goes wrong interpersonally for a given client. In the presence of others, clients may exhibit isolating patterns, become self-protective, or engage in off-putting behaviors, all too often without even being aware of them.
Dave was a pleasant young man who came to see me for depression and social isolation. He’d suffered several important losses—his wife divorced him and then he lost his job—and was stuck in a stressful family situation of caring for a chronically ill relative. Through individual treatment, he grieved for his losses, and his mood improved; however, he couldn’t seem to develop social relationships, and he remained lonely. Friendships seemed to begin well, but never deepen. Neither he nor I was sure why, as he was bright and, when encouraged, a warm, forthcoming person.
After he joined a group that I lead, however, I began to understand what was holding him back. When other group members candidly shared their thoughts and feelings, he responded with agreeable, but entirely impersonal replies. He shifted the conversation away from any emotional engagement, making the others feel unheard and unacknowledged. For instance, he might respond to a member’s painful story with “I bet things will work out in the end,” or pick up on the least emotional aspect of a situation and inquire further about that.
When I shared this observation, using specific examples from group sessions, he was dumbfounded. His deflecting style was completely automatic behavior, developed years before to protect himself from intrusive and prying parents. But once he recognized it and acknowledged the old, lingering anxieties that he circumvented by not revealing anything about himself, he began to connect more directly with other group members and people outside the group.
Group therapy is a highly effective laboratory in which to practice new behavior and get honest feedback from others. The woman who consistently tells her individual therapist that she never gets her needs met in relationships may discover in group that she behaves in ways that inevitably make sure that others overlook her. The group members will let her know that if she doesn’t speak up, she will be overlooked. Members will ask where she learned how to be overlooked, and will encourage her to take the risk of asking for attention. The “nice guy” who’s always afraid of offending someone can express irritation with another group member and learn that the world hasn’t ended, and that he’s still accepted by the group.
In an effective therapy group, the majority of the work takes place in the room: although members talk about their lives “outside,” the real action is the moment-by-moment back-and-forth among group members. The group leader’s role is to help participants give constructive and honest feedback to each other—sometimes called the “hall of mirrors”—and avoid giving criticism or advice.
Because a well-run group offers a safe, contained space, it can help members try out new behaviors or ways of interacting that they wouldn’t attempt elsewhere. A large part of the leader’s role is to encourage members to try out new behaviors and responses. One group member, Susan, was the daughter of an unpredictable and intrusive mother. She’d learned to protect herself by always being in control, to the point that, in the group, she assigned herself the task of monitoring the process and drawing in silent members, as if she didn’t trust me to be the group leader. In one session, I invited her to experiment with allowing herself to let me be the one in charge. After stepping back during the session, she reported that she was amazed at the level of anxiety she experienced, and the strength of her long-buried yearning to allow herself to depend on someone else. She later said that she felt safer letting me be in control in group than in an individual session, because of the perceived protection of the other “siblings.”
In fact, although prospective members often imagine that the presence of the other members makes group therapy more anxiety-provoking, the opposite is often true. The group can actually support an individual member, especially when there’s a conflict or another issue with the group leader.
I once made a mistake in tallying the bill of a meek, superego-burdened group member. Raised by harsh, perfectionist parents, she’d never before stood up to authority. But with the encouragement of her fellow group members, she was able to tell me that the mistake had made her mad, and that she doubted my competence as a result of my error. She wouldn’t have dared stand up to me in a one-on-one session, but the group support gave her courage.
For group therapy to be effective, any new members should be up to the level of the group. A person who can’t describe what he’s feeling and experiences only body sensations won’t do well with group members who are more fluent in speaking about their emotions, but this same person might do well among people who have difficulty articulating their feelings. The basic requirement of membership in a group is that the client must be able to uphold the particular group agreement or contract, which typically covers attendance requirements, payment, confidentiality, limits on outside contact with group members, termination procedures, and the role of the leader.
Today, there are many varieties of group therapy, including standard interpersonal or psychodynamic therapy groups; open-term or time-limited groups; and CBT, psychodrama, and DBT groups. There are groups for specific populations or themes: men, women, gay, eating-disordered, first-break psychosis, medical illness, social anxiety, mind-body, and, of course, addictions. Naturally there are now cybergroups that make a group experience possible for people living in isolated places.
Groups have many healing qualities, but one of the most important is the basic human support they provide—giving a sense of belonging and group cohesion, factors that are increasingly scarce in our fragmented society. One client, reflecting on what he’d gained from the group as he was terminating therapy, said that what he found hardest to leave was the sense of being part of something—the feeling that the group was always there for him in a basic way. “My life is so much better, and I am so grateful,” he said, “but I’ll just plain miss being here with you guys every Tuesday evening!”
So why isn’t group therapy a more widely used treatment? For one thing, many insurance policies will pay for only a fixed number of visits, so group members who want to continue past the allotted 10 or 20 sessions must pay out of pocket for much of the year. This is a false economy on the part of the insurance companies. Since group sessions are so much less expensive than individual sessions, the reimbursement for a dozen private sessions would pay for the better part of a year of group sessions.
Another issue is client resistance to joining a group. Some clients are afraid they’ll get less attention from the therapist in a group—”I don’t want to share my therapist” is a common refrain. Other reactions include “How can a group of people with problems help me?” or “I can’t imagine telling my problems to strangers” or “What if I don’t like the group—or the group doesn’t like me?”
These concerns are legitimate. It can be scary joining a bunch of strangers, with whom intimate personal stories will be shared, and sometimes it doesn’t work out. I’ve never had a client who didn’t like at least one person in a group, although I’ve had clients who came to feel they weren’t in the right group.
What skills does a good group leader need? One of the most important is the ability to do mental multitasking. You’ll usually be thinking on at least four levels at once: about the individual members, the interpersonal interactions, the group as a whole, and your own internal reactions. Some therapists are not good at this, preferring the more intense focus of individual treatment.
Other clinicians dislike the exposure involved in leading a group. In fact, it is more uncomfortable to make a mistake in front of six or eight of your clients than to make one in the relative privacy of an individual session. I was genuinely embarrassed when I made the billing error with my client. While I knew that what my client did was therapeutic for her, it still stung me, all the more so because it happened in front of an audience—one that was pleased to see me brought down a peg, I might add.
Clinicians without a substantial referral base may find it too difficult to keep their groups filled. It’s demoralizing to have a group dwindle down to two or three members. Some clinicians have formed group-therapy networks to solve this problem, marketing the network and referring to each other’s groups. Involvement in local and national group-therapy associations can help keep group referrals coming too.
Should you just start a group yourself? Definitely not without specific training! The American Group Psychotherapy Association (www.agpa.org) has developed guidelines
for becoming a Certified Group Psychotherapist (CGP), and the parent group and its local affiliates offer many fine training opportunities.
Group therapy can be an excellent treatment for most clients. It’s cost-effective, and in many ways a better mirror of “real life” than individual therapy. Whatever happens in group, you’ll never be bored!
Eleanor Counselman, Ed.D., C.G.P., F.A.G.P.A., is immediate past president of the Northeastern Society for Group Psychotherapy and an assistant professor of psychiatry at Harvard Medical School. She’s published numerous articles on psychotherapy and has a private practice in Belmont, Massachusetts. Contact: EleanorF@Counselman.com. Tell us what you think about this article by e-mail at firstname.lastname@example.org, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine section.