“I’m sorry for canceling on such short notice, Dr. Daitch. Therapy was really helpful,” Bill began half apologetically. “You taught me how to keep my cool when Denise criticizes me, instead of exploding at her, but it just isn’t working. I know about active listening and validation. The problem is that when I’m home, I just can’t do it: I can’t stop myself from overreacting. She starts nagging, and before I know it, I’m screaming at her. It’s not your fault. Therapy’s just not the answer for my problem.”
How could I argue with him? He was describing a common dilemma for clients: in the contained, nurturing therapeutic setting, it’s relatively easy for them to learn rational reactions and rehearse intentional responses. But life comes at you fast, and it’s extremely difficult for clients to transfer these skills to actual situations, when they’re suddenly overwhelmed by their emotions. The stress, anger, and anxiety evoked by everyday confrontations and interactions can easily overwhelm our clients’ best intentions, completely dislodging newly learned techniques for keeping their cool—no matter how much they practice these techniques in sessions. At that point in my practice, I had no idea of how to help emotionally overreactive clients take what they’d learned in therapy into their lives outside my office.
That was 10 years ago. Bill didn’t resume therapy with anyone, and a year later, I heard that his wife had divorced him. The only good outcome of that case was that I determined then and there to develop specific techniques for helping clients do in their daily lives what they’d learned to do in my office. Today I not only teach emotionally overreactive clients techniques for calming themselves down, but include practice and rehearsal time in sessions and follow up with them between sessions to make sure they’re practicing regularly at home. Without this kind of transfer of skills from therapy to daily life, therapy is futile.
Helping clients regulate affect and alter their own response patterns is enormously challenging because we’re faced with the daunting task of intervening in the hardwired neural processes of the brain. The brain’s 100 billion neurons are connected in extraordinarily complex ways and wired by evolution to react to upsetting external stimuli with behavioral responses based on fear or anger. That’s why it’s much easier to express negative emotions than to manage them with reason.
As clinicians, we not only have to teach our clients how to interrupt old coping mechanisms, generated by fear and anger, and apply new ones, but also how to integrate the new coping skills permanently into their response repertoire. Successfully combating and overriding firmly ingrained behaviors and reactive styles in this manner requires practice, and it’s our job as therapists to help clients learn how and when to practice these skills, and then make sure they go home and do it.
Our clients need to do their part, of course. Many implicitly expect that the therapy process itself will magically improve their lives and relationships all by itself. We need to bring up this fond hope, challenge it, and get them to understand that they themselves must play an active, ongoing role: learning to control their own automatic emotional responses requires self-discipline, commitment, and practice. Clients must understand that we’ll be there with and for them, but that without their own efforts, therapy is unlikely to give them what they want.
The framework I utilize to facilitate transfer can be broken down into three basic components: the homework contract, visualization, and implementation.
The Homework Contract
From the beginning of therapy, I emphasize the importance of homework, telling clients about research demonstrating that willingness to engage in homework is directly related to the success of therapy. In fact, I make homework compliance a condition of therapy, while reassuring them that I’ll teach them explicit techniques that’ll help them engage in practice consistently. I remind them that, by itself, the work we do together in our sessions may not be enough to get them the results they want, but committing themselves to practice dramatically increases their chances for success.
During every office session, I help clients visualize themselves engaging in their newly learned behaviors and practicing these techniques at home. For example, I might have a client rehearse the use of positive self-statements and deep-breathing to increase calmness, all the while imagining a spouse berating or criticizing her. Then we’d rehearse ideal reactions. An added benefit is that this exercise helps clients anticipate the kinds of situations that’ll require them to use these new tools.
Following the behavioral rehearsal, we rehearse the practice sessions that the client will do at home. I do this because I’ve found that clients need to practice practicing! In therapy, I direct clients to visualize an extended daily practice, mini practice sessions, and a number of typical scenarios in which they’d likely be triggered and then successfully use the new, calming tools to maintain equanimity. Visualizing the practice sessions helps clients realize that it’s feasible to integrate them into their daily lives and enhances commitment. Clients begin to understand that using this kind of affect regulation can be part of a lifelong discipline.
I typically use hypnosis for helping clients rehearse new ways of behaving and committing to homework. But people who aren’t trained in hypnosis can teach clients to relax with a few deep breaths, and then have them visualize (with eyes closed, if comfortable) doing the new behavior.
I provide clients with four discrete types of practice session that are briefly rehearsed at the close of each therapy hour:
Extended Time-out – One Daily, 20-Minute Session
A daily practice of meditation or self-soothing mitigates the negative effects of stress. Accordingly, I ask each client to choose a time and a place in which he or she will relax each day for 15 minutes, followed by 5 minutes practicing a newly learned therapeutic skill. I teach my clients self-hypnosis to enter this calm state of being, but progressive muscle relaxation, guided imagery, systematic desensitization, mindfulness, and other forms of relaxation will work as well. Once clients have established a specific time and place for this meditative exercise, I encourage them to set reminders, such as programming a daily reminder on a PDA or cell phone. Day planners or Post-it notes work just as well for the less technologically adept. I seek the verbal commitment of each of my clients to engage in the practice sessions, follow up on the client’s interim practice at each session, and sometimes phone between sessions, just to check in and see how the practice is going. My clients and I have sometimes joked that I’m really their thera-pest. But often a five-minute phone call or a brief voicemail message is all an errant client needs to get on the ball and start practicing.
Mini Sessions – Up to 3 Minutes, Several Times a Day
These mini breaks help clients develop a working resiliency to stress, thus preventing emotional overreactions to trigger points. I direct my clients to carry out these sessions regardless of their current affective state and suggest that they time them to coincide with routine daily events. For example, a client might take a moment and turn off the radio and cell phone in the car to practice slow, deep breathing and positive self-talk on the way to and from work. Another good practice time for a routine mini session is before a client eats a meal or snack.
External Time-Out Sessions – Variable Duration and Frequency
These are “interruption” sessions to be practiced at exactly those times when clients are caught up in the heat of the moment. Why not excuse yourself from the conversation before you holler that insult at your spouse? Why not excuse yourself to the restroom before you react defensively when your boss criticizes you during the staff meeting? When triggered or overwhelmed, clients can excuse themselves for a moment to practice their therapeutic tools—calming responses, positive self-statements, visualizations, or replacement behaviors. Once they find an inner place of emotional equilibrium, they can rehearse a desired response to the current situation. Then they can return to the situation at hand with a calmed nervous system and desired responses on the tip of the tongue.
Internal Time-Out Sessions – Variable Duration and Frequency
What about those times when you need a break, but just can’t get away? You can’t stop your car in the middle of the highway for a time-out to interrupt the start of a panic attack, nor can you always bolt from a board meeting when you feel your fury rising at the snide remarks of your double-dealing coworker. Internal Time-Out Sessions offer a kind of respite in situ, taking 5 or 10 seconds and drawing no more attention than a gentle sigh. I teach my clients to discretely tighten a fist when they feel their stress mounting, hold the fist for a few seconds, and then release the muscle tension as slowly as possible, focusing all their attention on the relief that the gradual unclenching brings. If the situation doesn’t require maintaining eye contact, clients can close their eyes and roll their pupils upwards, as if trying to reach the upper arc of their eyebrows. If the situation involves listening rather than speaking, I suggest clients take 10 seconds to focus all their attention on the slow, inaudible inhalation and exhalation of their breath. All of these 10-second tools, when paired with relaxation in the therapist’s office and practiced during mini sessions, can act as quick circuit breakers, diffusing internal tension while operating below the social radar.
Principles in Practice
A few years after my sessions with Bill ceased, Don was referred to me by a colleague who’d been treating him and his wife, Cara, in marital counseling. They were in their mid-fifties and had been married for 25 years. Cara was a nonpracticing teacher; Don was a minister. While good at counseling and supporting other people, Don was helpless to control his own fury at perceived criticism from his wife. Her body language or tonal inflections alone could elicit a strong reaction. At least several times a week, he’d become flooded with a venomous rage at his wife, attack her verbally with great hostility and contempt, and even follow her from room to room trying to extract what he felt was a satisfactory response from her. Cara would completely shut down and stonewall, often withdrawing from Don for days. This pattern—of perceived criticism from her, fury and contempt from him, followed by her cold withdrawal—exacerbated his feelings of rejection and anger.
By the time Don was referred to me, the couple was feeling hopeless and discouraged by the emotional climate of their marriage. At the end of her rope as Don’s angry outbursts continued in spite of their hard work in therapy and the insights about their marriage, Cara was threatening divorce. At this point, Don agreed that marital therapy wouldn’t be effective unless he mastered his knee-jerk defensive reaction to her perceived disparagement. He decided to see me in conjunction with the joint therapy work he and Cara were doing.
The referring therapist reported that the couple had mastered many essential components of their marriage therapy while in session. In addition, Don had considerable insight into the dynamics of his relationship with Cara, and how earlier childhood wounds were being replayed in his marriage. He “understood” his marital impasse well, and both he and his wife were quite expert at applying new strategies while they were in the therapist’s office. But at home, it was another story. There, time and time again, Don couldn’t overcome the considerable hostility he felt in the heat of the moment. He didn’t need to learn communication skills—he had those down pat. Rather, he needed to learn how to diffuse his reactivity, so that he could apply the new communication skills at home with his wife.
Don was worried and upset when he came into the office—afraid his marriage wouldn’t make it and distressed about his out-of-control rage at Cara. But his entire frame relaxed when I told him he could learn a handful of techniques for diffusing his reactivity. As always, I emphasized that his mastery of these techniques depended entirely upon his commitment to practicing them every day.
We first worked on developing his ability to practice his daily 20-minute relaxation session. Although Don was eager for his outbursts to lessen and gave me a verbal agreement to practice, he appeared hesitant about incorporating the extended practice sessions into his daily life. So we closed our first session by “practicing how to practice” with the visualization of his setting his alarm that night to ring twice the next morning—the first time to wake him and the second time, 10 minutes later, to remind him to practice. Due to his seeming reluctance, I made a note to call Don in two days to see how his practice sessions were going.
Don’s first practice sessions at home consisted simply of invoking and maintaining a state of calm relaxation. “Well, I didn’t set my alarm, but I did practice yesterday morning anyway, although not this morning,” he said to me when I called on the second day of his new regimen. He warmly thanked me and expressed his surprise that I’d taken the time to call and check on him. He was also surprised that I didn’t chastise or lecture him for missing that second morning. Instead, I conveyed my commitment and investment in his progress, and told him I’d look forward to hearing about his practice sessions during his next visit. While on the phone, I had him take a moment to close his eyes, take a few deep breaths, and again visualize himself setting his alarm that evening and practicing the next morning.
At the next session, a smiling Don reported consistent practice following my phone call. He also said he couldn’t generate a relaxed state easily, so we moved on to learning some new “circuit breakers,” as well as rehearsing some external time-out sessions.
In my work with highly reactive clients, once they can easily access a calm baseline, I elicit the problematic excited state and diffuse it there in my office, teaching them a variety of tools they can use to do the same for themselves outside of therapy. So I asked Don, while in a state of relaxation, to recall a recent conflict between him and Cara, particularly the moment when he felt overcome by his rage. I then directed him to revive this feeling, becoming aware of where in his body he held the tension. Once he’d identified the somatic cues of imminent overreaction, he was to visualize excusing himself, telling Cara that he was taking a time-out and would be back in just a couple of minutes. I suggested that he then imagine going where he wouldn’t be disturbed—the bathroom or outside the house—and doing some of his relaxation exercises.
In his ensuing sessions with me, Don learned how to do regular mini sessions and internal time-outs—the latter proving to be particularly helpful when he and Cara were in the car together and he had no ready escape. As time passed, Don reported that he sometimes began replacing external with internal time-outs, finding it less necessary to separate himself from Cara to implement his new, calming techniques. With the aid of a few more between-session phone calls, he adhered to his practice and began to incorporate his new tools successfully. He saw me 12 times over six months—weekly for the first two months and then monthly for reinforcement sessions. Unlike Bill, Don concluded his sessions with me feeling he was able to make use of what he’d learned in therapy even when triggered by the unexpected but inevitable conflicts in his relationship. His marriage is intact today.
How long does it take to change ingrained habits and patterns, or for fears to diminish? Some things can change quickly—specific phobias can diminish within three to five sessions, for example. Generally, however, it takes many practice sessions for habituated reactive responses to change, and for brain patterns to rewire. The key word in how to accomplish this is practice.
I’ve found that when I stick to the firm expectations and structure of the homework contract, visualization, and implementation, practice becomes a regular feature of my clients’ therapy. This, in turn, increases the likelihood that they’ll be able to transfer the skills learned in session to their daily activities and succeed at changing their lives. In the end, practice may not make perfect, but it certainly helps.
Carolyn Daitch, Ph.D., is director of the Center for the Treatment of Anxiety Disorders in Farmington Hills, Michigan. She’s a certified and approved consultant with the American Society of Clinical Hypnosis, a consultant with the University of Michigan’s Program of Integrative Medicine, and a certified Imago Relationship therapist.