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How Conversation Sparks Therapeutic Change - Page 4

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Search for Competence

As a theme develops with our clients, their unspoken self of hidden competencies often begins to surface. One of the best paths to competence for clients who've never before been able to experience themselves as successful human beings is to discuss with a truly interested therapist what most engages them in life and brings out their natural urge to get better at something. Not surprisingly, though, those conversations don't always take the form of what we usually think of as therapy-speak. More often than not, a sense of competence and coherence comes out of conversations that aren't a linear attempt to buttress a client's self-esteem. For example, almost nothing can boost a client's confidence more than cracking up--and I'm not talking about a DSM diagnosis. People appreciate humor and enjoy feeling that they're funny. In fact, in current surveys of the general population, humor is now ranked high on "most admired characteristics." This makes sense for generations growing up on a steady diet of Saturday Night Live, cable TV, raunchy movies, and standup comedy for every taste. Of course, humor can cut both ways, but as long as we understand a patient's sensitivities, laughs can't help but find their way into engaging conversation.

As with many learning moments for me, ingrained proscriptions about the role of humor in therapy changed unexpectedly. Harold was a thirty-something, deadpan kind of a guy who suffered from complex childhood traumas, which created severe anxiety attacks. After the initial phases of treatment, Harold said he couldn't tell me something extremely important. Though he called it "crazy," he believed that people would somehow know if he spoke it out loud, look at him strangely, and laugh derisively.

After trying all the usual techniques for resistance and shame, I decided to start a conversation in a slightly different way. I asked Harold, "Well, how about if you and I both put on a pair of Groucho glasses and you can tell this secret more 'anonymously'?" Forget for a moment that Groucho glasses don't make me look a smidgeon different than I already do. However, at the exact same instant we were sitting there in our "disguises" finally discussing Harold's (quite ordinary) concern, two house painters on a scaffold serendipitously descended and stopped right outside the window. Guess what? They started pointing at us, laughing with great zest and, I do believe, derision. Harold's paranoid fantasy had become a reality, only now we were both rolling on the floor, hysterical ourselves.

After we two Grouchos vigorously gesticulated at the painters, Harold suddenly began talking about how he'd always had the ability to make people feel cheerful. I could see that myself now--since I don't normally use stage props in treatment. We then went back and forth about the ironic quirks of family life, as well as stories about fun times that had been interspersed within his family history of chronic loss. Harold had recovered his unspoken and competent lighter self: the ability to bring cheer into people's lives. His contagious good humor slowly became a central part of the way he thought of himself in the world, influencing his choice of a marriage partner, how he dealt with the multiple sclerosis that later developed, and his career decision--to become a therapist.

Don't Fear the Trivial

Conversations that yield a sense of competence in the consulting room, like those that take place in the rest of our lives, often begin with curiosity about the mundane. But as in any other kind of human exchange, "the truth is in the details," especially when using conversation to highlight aspects of the self that have previously remained hidden for too long.

Ben was in the depressive phase of a suspected bipolar disorder. Extremely high functioning, he'd had to leave a job in another city, go back to living in the family's basement, and enter a day-treatment program. One day, he mentioned that in the middle of feeling depressed and unable to remember what kind of cognitive distortion he was dealing with, he'd forced himself to make a sandwich. By this time, I'd also had enough of therapy-talk (a sure sign that you need to mix it up a bit), and seeing a slight glimmer in his eye, I said, "Sandwiches, I love sandwiches! Tell me what you put on this one."

Ben said "What in the world does this have to do with therapy?"

I replied, "Maybe nothing. But you look like you enjoyed it. I'm gluten and dairy intolerant, and any chance to hear about a good sandwich, I'll take."

So Ben described in great detail, every part of the sandwich. We spent almost the entire session on this, with me wondering as one often does in these conversational U-turns, "What in the world am I doing?"

But Ben loved it, and so did I. A theme emerged, not about sandwiches, but about the trivial details his sharp eye took in. Ben's face lit up as he described the features of anything he was into, and he enjoyed listening to my reactions. This newfound ability to appreciate his capacity for paying attention migrated from the consulting room into relationships. Previously, a self-involved young man, now he actually began listening to his friends, with great success. This love of detail then found its way onto the Web. He started to blog about the subtleties of twenty-something friendships, attaining a small but growing audience. At the end of each session and with all the therapeutic authority I could muster, I'd remind him to keep paying attention: "Ben," I'd say, "when in doubt, look to the sandwich!"

Barriers to Conversation

Creating an alive conversation in the consulting room has a lot going against it. For one thing, the scripted therapeutic tone we all learn makes us superficially sound very much like one another, at least in our own minds and in the view of pop culture. TV's top therapists and fictional shrinks, the real life Dr. Drew (Pinsky), as well as the imaginary Dr. Melfi (The Sopranos) and Dr. Paul Weston (In Treatment), all have that canned therapist sound. But I'll bet if you taped your own sessions (with your clients' permission, of course), you wouldn't sound anything like the constrained professional. Your empathy, humor, and impatience--in other words, much of your human repertoire--would show through, despite the model of therapy you practice. That's the way it should be.

But alive conversations that actually energize the therapeutic process face another obstacle. Not only does training in various models of treatment inculcate certain conversational patterns, even vocal tones, in us, but patients also elicit responses that constrain our own conversational freedom. As psychoanalyst Edgar Levenson described decades ago in his revealing explication of how countertransference works, we're all "transformed" by the people we see in our practices--for better or worse we become their historical figures. We can't help it, but this disquieting phenomenon is an uncanny guideline to new, potentially reparative exchanges. So, as you follow a patient, always watch for the ways you've become "not you" and reflect on how taking another tack might encourage a more positive interaction. Understanding how we've been transformed is a "tell" that will guide us to the client's unspoken self.

What exactly should you pay attention to in yourself that reveals how you've been transformed by your patient? First, look closely at how you may be acting or feeling differently than you usually do. Pay attention to the thoughts, feelings, images, and even the songs that flit across your consciousness, and certainly to any fantasies in session and your dreams at night. Carefully notice your voice tone, by which I mean warmth, decibel level, cadence, and so on. Of course, be aware of the flattened or negative states you may be experiencing with your client. You shouldn't be ashamed of these--just the opposite. If you follow them, they usually lead to a therapy issue that needs to be addressed; one that can reveal the unspoken self.

With Naomi, a street-smart, impatient young woman, dismissive of me and therapy itself, I found myself uncharacteristically annoyed. Like many clients today, she had a cell phone that occupied her attention all session long. I couldn't get a word in edgewise, until, largely out of pique, I brought my own cell phone into the consulting room. Every time her device announced a text, I checked my own for messages. This got her attention.

"What are you doing?" Naomi yelled. "You're supposed to be listening to me!"

I responded, "Well, if you're not saying anything, I'm not going to waste my time either."

"But that's what you're being paid to do!"

"Not nearly enough for this!!!" I sharply responded. Remembering Levenson, I recognized this "transformation" into becoming her aggressive mother and shifted my focus to say a bit more warmly, "Well, instead of wasting each other's time, I'd rather talk about who's calling and texting you so often. Forget about you, I'd love to know more about them."

Naomi's face softened a bit, and she began hesitantly detailing one of the texts. In the next session, she described more of her friends' texts, along with their temperamental and family issues. I responded in many different ways--sharing what I thought about each of them based on her descriptions, telling her about how they reminded me of my old friends, and so forth.

Once I'd gotten past this adversarial transformation, I discovered that Naomi was extremely articulate--rarely have I heard someone speak so lucidly and with such descriptive power. Round and round we went in our weekly discussions; my only Naomi-focused observations were brief references to how articulate she was. She never seemed to fully absorb these positive comments. But, gradually, I began hearing them in her newfound sense of confidence and competence, as if she'd come up with this viewpoint entirely on her own--an experience I've become used to when nonlinear conversation is a central part of therapy.

Conversation and Self-Disclosure

Over the years, we've seen a growing literature about the power of strategic self-disclosure in therapy. And, whether we admit it or not, most of us engage--consciously or unconsciously--in some sort of self-disclosure during every session. Yet, we once again employ a form of clinical double-bookkeeping, practicing self-disclosure regularly while being careful not to let our supervisors know how much of ourselves we inject into our supposedly self-effacing sessions. The problem is that most of us have precious few guidelines on how and when to self-disclose in a way that's actually therapeutic. Of course, when and how and with whom depends, as always, on your client and the circumstances. But if self-disclosure leads to conversation in which you and your patient are both fully engaged, it's probably a good idea. And if the more competent and emotionally present unspoken self of the client begins to make an appearance, then you're on the right track.

Irene is in her fifties. A single mother of three, she's a journalist covering genocidal wars. She suffers from bouts of severe anxiety and, perhaps not surprisingly, struggles with crippling political and personal guilt. Although she's seen plenty of horrors, she isn't always empathetic toward herself or others. Irene tends to dismiss noncatastrophic suffering as unimportant, and feels that talking about it is whining. Therapy was partially effective in that she'd started to feel less anxious and perhaps a little less intrinsically guilty, but it soon reached a stalemate--slightly arid and a bit predictable.

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