"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.
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.
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.
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.
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.
Carolyn Daitch, PhD, 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.
This blog is excerpted from "Practice Makes Perfect" by Carolyn Daitch. The full version is available in the September/October 2008 issue, How Evolved Are We?: The Triune Brain in the Consulting Room.
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