There is a moment that we therapists savor above all. We've just done or said something decisively effective and put our client in touch with a deep emotional reality. Before our eyes, a shift takes place—a shift in both mind and body—and the client slips from the grip of a lifelong pattern.
Two decades ago, seeking both depth and brevity in our clinical work, we began going over the process notes and audiotapes of thousands of our interactions with clients, especially those that yielded the most powerful turning points. What, we wondered, had happened differently in those sessions? Could we find a way to focus and organize depth-oriented therapy so that transforming moments could occur from the very first session? And could we fashion a brief therapy that could dive deep into unconscious emotional realities without sacrificing much-valued speed and focus?
We discovered that what distinguished the pivotal interactions was that—whether due to serendipity, curiosity, desperation or fatigue—we had completely stopped trying to counteract, override or prevent the client's debilitating difficulties. We had ceased offering communication tools, more "rational," positive beliefs, insightful interpretations, better narratives, systemic interruptions or clever reframes.
In short, we had stopped treating the symptom like the work of a demon whom we were trying to drive out of the client's life. We had focused instead solely on learning from the client why their depression, panic attacks, stormy relationships or obsessions were somehow necessary—what unconscious benefit these seemingly nefarious symptoms served. We were fascinated to find that by focusing therapy in this way from the first session we could get powerful results swiftly and reliably.
We began to pursue a new therapeutic strategy, centered on the premise that, from the first session, unconscious constructs requiring the symptom are immediately accessible. This was foreign to our training, and initially we had to bite our tongues and shed our habitual tendency to counteract, override or push away the symptom. Now, many years and clients later, we have developed an approach we call Depth-Oriented Brief Therapy (DOBT) based on the insights we have gathered along the way. The following case demonstrates our approach and how we help clients by heading straight for the emotional truth of their symptoms.
A Black Cloud
Tina, a 33-year-old proposal writer, sluggishly began her first session in a dreary tone that matched her lethargic walk and slouch. Her stringy blonde hair was unwashed and she wore a dingy gray sweatsuit stretched across her bulky body. Her presenting symptom—the hated demon she wanted out of her life—was depression. "I've been feeling depressed and lousy for years," she said, almost without preamble. "I have a black cloud around me all the time."
Tina seemed bored with her own story and told it as though talking about someone else. Supposedly working full-time for a nonprofit agency, she could bring herself to spend only 10 hours a week writing grant proposals from home. Her relationship with her partner, Ralph, consisted of little more than "parallel lives." Nothing she had tried had helped her—not two previous attempts at therapy, nor the two self-help groups she desultorily attended nor prescriptions for Prozac or her current medication, Wellbutrin. Gazing at the floor, she said, "I just don't know why I can't be happy."
When Bruce—the therapist in this case—asked her what was hardest about her childhood growing up in New York City, she spoke about her family in cynical tones. "In my family, the words 'I love you' are a way to hang up the phone," she said. 'There was no affection—and no other feelings either. Except anger. Anger is fine. Putting each other down is fine. Which did wonders for my self-esteem. With self-esteem as low as mine is, why shouldn't I feel depressed?"
Tina was a daunting client for a therapist seeking in-depth resolution in a few sessions. Bruce first asked Tina to reenter a recent situation in which she had felt depressed. Rather than merely getting her to talk "about" her symptoms, Bruce guided her toward directly experiencing them so that the underlying themes and constructs sustaining them could more readily be brought into awareness. He asked questions rich in concrete cues: "Where are you sitting? What time of day is it? What are you wearing? How does your body feel on the chair?"
Tina closed her eyes and imagined herself on a recent late afternoon at home alone, sitting at the kitchen table in her bathrobe. She sighed, and her body seemed to sink even more deeply into her chair. Moving beyond a merely cognitive description, she entered her felt experience--the core of her emotional life and the place where profound change is possible. She gave voice to leaden energy ("It's physically too hard to get up to answer the phone"); profound disinterest and inactivity ("I hate my job and heard about a much better one I'm qualified for, but I'm sitting here feeling, 'Who cares? Why bother?' And you know, I don't care about anything. I'm never motivated for anything"); self-denigration ("I'm a vegetable. I'm a worthless nothing that nobody could possibly find interesting, and Ralph must want to leave me"); social isolation and hopelessness. Identifying these specific features of her depression was an important initial step for gaining access to their underlying emotional truths.
As Bruce and Tina talked, it emerged that her symptoms had already appeared in childhood and were still at their most potent when she was with members of her family. To help her experience rather than only factually acknowledge this truth, Bruce asked her to visualize her mother, father and older brother. "Would you be willing to let the scene change now to your parents' house, and be there with your family and let yourself get into how you typically feel and how you act there with them?" Tina was silent for nearly a minute, then said, "I'm half dead. I'm an apathetic lump. I'm telling myself I have nothing interesting to say."
Bruce's job, as he saw it, was now to usher Tina into discovering why the inert state she just described was necessary for her when in the presence of her parents. "Okay," he replied. "You're a half-dead lump and inside you're actively telling yourself you have nothing interesting to say. Stay in that, and tell me: Was there ever a time with them when you did really have something to say, and you said it?" Bruce asked. "Something other than anger?"
"Hah!" scoffed Tina. "I'm stupid, but not that stupid."
"Mmm. Tell me how you know that would be a 'stupid' thing to do."
Tina recalled being 12, walking with her family out of the hospital where her grandfather had just died. She told her mother how sad she felt. Immediately her mother snapped, "Stop being so dramatic!" Her brother at once chimed in with disparaging jabs. "They cut me right down," Tina summed up matter-of-factly.
Bruce now understood that Tina's half-dead, inexpressive state was her means of protecting herself from being cut down again. It was also clear that although Tina had just articulated the reason that she kept herself in that state, she was not yet directly in touch with the emotional realness of it. To achieve this, Bruce simply reflected back to her the experiences she just described. "When you express your own sincere feeling, you get cut right down. Sounds pretty painful. But in the other scene, where you're a half-dead lump telling yourself you've got nothing to say, you don't get cut down. Is that accurate? How would you put it?"
Tina's eyes opened and her glance flicked around as she made the internal connections. Her words came with measured intensity: "Saying what I'm really feeling or caring about gets me shot down—so I don't go there."
"And how do you keep yourself from 'going there?'" Bruce nudged. Tina, perceptibly animated for the first time in the session, announced, "Being dead, apathetic and telling myself I have nothing interesting to say!"
She was now bumping into her own purpose for parking in that deadened state and beginning to glimpse her own agency in producing a symptom that until this moment had seemed to exist beyond her control. This pivot into conscious ownership of a formerly unconscious purpose is a milestone in the unfolding of Depth-Oriented Brief Therapy.
At her next session, Tina reported new realizations. She had known all along that her family members almost never expressed love or affection, but now she had recognized that in dealing with them she was "swimming with sharks." By playing possum on purpose, she also realized how reflexively she had done so in the past. Tina's new awareness had firmed up. The involuntary muscle that had unconsciously protected her with depression was coming under her conscious control.
This was Tina's first real breakthrough, but it addressed only one of several different, unconscious ways in which her depression was vital to her. Over the next two months, she returned for three more sessions, each time discovering, embracing and dissolving other deeply held constructs that made her symptoms necessary. By the fourth session, her sweatsuit was gone, her hair was clean and she was wearing earrings that sparkled as she tossed her head and reported on improved interactions with her partner. At the fifth session, remarking on her "relief and hopefulness" and confident she would find new work and explore new interests, she decided not to schedule further sessions.
When we called her two years later—last May—Tina was nine months into a new career in computer programming and full of enthusiasm about her future. She said she was free of the "black cloud" and was no longer taking antidepressants. She added, "The work I did helped me a lot. I could step back—that's been really nice. Things are good, in many ways," she said, and the vitality in her voice was fully congruent with her words. "Things are very good."
Listening for Coherence
In her carefully focused and intense sessions, Tina had experienced breakthroughs with a depth unlikely in brief therapy, and with a speed almost unheard of in traditional long-term therapy. What had worked for Tina was what we find works for a wide range of clients—a systematic and experiential approach that allows deep therapy to be brief, and brief therapy to be deep. We had not tricked or driven away the demon of her symptom, nor had we subdued it with intellectual insights or ingenious reframes. We had simply listened to what Tina's symptoms were telling us and helped her grasp her own most deeply held and long-unspoken constructions about the nature of reality.
Once she brought these unconscious constructs to light, other ways of dealing with the world and of solving her emotional dilemmas became possible. She could now safely let her personal world develop, while consciously deciding how much of herself to share with her mother and others. In this new landscape, she found that the depression that had once protected her was no longer necessary and it fell away, replaced by a new sense of well-being and self-worth.
This blog is excerpted from "Deep from the Start," by Bruce Ecker and Laurel Hulley. The full version is available in the January/February 2002 issue, Whatever Happened to Transformation?: New Approaches to the Art of the Therapeutic Breakthrough.
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Tags: Anxiety | anxiety and depression | breakthrough | brief therapy | Bruce Ecker | childhood depression | clinical depression | coping with depression | Depression & Grief | depth oriented brief therapy | dobt | Laurel Hulley | Parenting | parents | success