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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.
Wonder if Pac-Man and Ms. Pac-Man ever needed couples therapy? What might a family therapist say about the sibling rivalry of the Super Mario Bros? It’s time to get serious about gaming, because some suggest that video games and psychotherapy fit together like a well-placed Tetris block.
Surveys suggest that between 95 and 97 percent of American teenagers have played video games at some point in the recent past, and most of them play games on a regular basis. Adolescents aren’t the only ones gaming, however. More than 50 percent of adults play video games, too, whether they’re launching Angry Birds on their phones or questing in multiplayer online universes like World of Warcraft.
“They’re a part of our patients’ lives,” says Mike Langlois, a clinical social worker in Cambridge, Massachusetts, and author of the eBook Reset: Video Games & Psychotherapy. “Anything that much of the population is doing is something that psychotherapists need to know about.”
Unlike the arcade games of the past, modern video games offer an immersive social experience that therapists can use to build relationships with young clients. Forget about the dusty old board games like checkers and Parcheesi! “If I’m doing play therapy with adolescents in the 21st century,” Langlois says, “I should be playing the games of adolescents in the 21st century.”
More and more, gaming consoles are making their way out of parents’ basements and into our offices. “As I’ve learned in my child and adolescent psychiatry practice, the focus should be not only on what kids play, but also, perhaps more so, on how they play,” writes psychiatrist T. Atilla Ceranoglu in an editorial for the Boston Globe. Ceranoglu’s research on the use of video games in psychotherapy suggests that by playing video games with their patients, psychotherapists can build relationships with their gamer clients. In the process, they can learn valuable information about frustration tolerance, creative problem-solving, competition, and collaboration.
Even if you don’t have an Xbox set up in your office, it’s important to be aware of and sensitive to gaming-related issues, says Langlois, who brands his clinical practice as “gamer-affirmative.” By talking to everyone from adolescents to active-duty military veterans in Iraq and Afghanistan about their gaming experiences, Langlois says he started to hear stories about how people used video game communities to get help when they were depressed or even suicidal. “It was very different than the media hype I was hearing about how video games are all addictive and cause isolation.”
Now researchers and practitioners are starting to catch on to the power-up potential of video games for clinical practice. Research studies have found that playing video games improves pain management during medical procedures, while some specially designed psychoeducational video games have been used to increase treatment adherence in managing chronic diseases, such as diabetes and sickle-cell anemia. Businesses such as San Diego–based SmartBrain Technologies and Atlanta-based Virtually Better are headed by psychologists to develop, test, and use special therapeutic video game programs for everything from brain injuries to AD/HD and panic disorder. Even major commercial entities like Nintendo’s Wii gaming system and Microsoft’s Xbox Kinect platform are marketing games to improve physical activity and mental coordination.
Meanwhile, if you want to improve your own gamer-practice competence, try video gaming yourself. “I don’t think you need to play every single game, but you do need to be willing to have the experience of playing a game and learning to play,” says Langlois. He’s started a class on social work and technology in which one session requires students to attend in the online environment of World of Warcraft. Some students new to the game environment (gamers might call them newbies or noobs) find themselves fumbling around and frustrated as they learn the intricacies of navigating a new world. “I tell them to pay attention to that, because that’s exactly how their patients feel. For them, life is as difficult to negotiate as learning how to navigate this video game is for you.”
Video Games: Review of General Psychology 14, no. 2 (June 2010): 141-46; http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2011/07/05/video_games_can_be_healthy/.
By Rich Simon Most of the therapists I speak with these days—both those brand new to the profession and the old pros who still nostalgically recall the pre-Managed Care era—seem to feel a lot like Gary Lockwood, the untethered spaceman in the great, prophetic movie 2001: A Space Odyssey.
You remember Gary, cut loose without oxygen or supplies by the malevolent computer HAL, whirling head over heels helplessly out into space. Read more
By Rich Simon Clearly these are challenging times for psychotherapists. In university training settings, public agencies and private practices around the country, there’s more and more pressure to do briefer and briefer work and less time than ever being devoted to discussing our cases and reflecting on our craft. Even veteran practitioners used to long waiting lists are seeing more and more appointment hours yawningly empty, while newer clinicians can barely keep their financial heads above water. Read more
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 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.
By Rich Simon Like a lot of us in this field, I’ve had boatloads of therapy over the years, but never a coach. At least not until recently, when Andrew—my 26-year-old basketball coach—came into my life to school me in the fine art of the crossover dribble and how to slide my feet on defense. At no extra charge, he’s also begun providing me with some of the best therapy I’ve ever received. Read more
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: email@example.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.
Debbie, who’s in her fifties, called: “I’m so upset about my relationship with my daughter. She and I are always in conflict, and my husband agrees this needs to be changed.”
When she came in, she reported feeling sad because she couldn’t enjoy visiting her daughter, an only child who lives nearby. “It’s such a noisy household. The children scream and squabble; there are two of them under the age of 6. I wish my daughter would be more organized and keep them quiet, so I could enjoy being there. I get so tense, I have to leave her home in the middle of a visit.”
I didn’t have a clear strategy, so I asked her to bring her daughter, Emmy, next time. Then the dynamics became clear. Emmy is a high-energy, outgoing, modern, in-your-face 35-year-old woman. Mother Debbie is quiet, somewhat distant, a loner, who needs her space. I was reminded of the movie My Big Fat Greek Wedding. Mom is a lot like the uptight couple who come into the vibrant Greek gathering.
During the hour with Mom and daughter, it became clear that Emmy wanted her mother to change and just enjoy her high-energy household. “Why can’t you be like other grandmothers, and just come in and enjoy the family?” And Mom wanted Emmy to change. “Why can’t you be more organized and quiet, so I can be comfortable with you? I can’t stand all that commotion.”
First, I tried some conventional strategies, like helping them listen nonjudgmentally to each other, but there was no movement in their relationship. I didn’t see any point in seeing them together again, so I asked Debbie to come in alone.
Again, she told me, “It just isn’t me to be like other grandmothers who get on the floor and play with the children and enjoy all the noise. And I like me the way I am. She’s asking me to be someone I’m not.”
I assured her: “You’re fine just as you are, and Emmy is fine the way she is. You just happen to be very different personalities. She’s AM, and you’re FM: she’s rock-and-roll, and you’re chamber music.” She agreed.
“Fortunately, there’s a solution. I’m thinking about Meryl Streep, and how she takes on a different personality for every role, but off-stage, she’s still Meryl Streep: she doesn’t have to change who she is. I wonder if you’d enjoy inventing a role that works well when you’re with Emmy and her family? (Here, I slowed to my hypnotic voice and watched her slip into a trance.) When you open the door to her home, you can see it like a stage. You pause at the door, view the scattered toys, and listen to the active children as part of a stage set. You may find it amusing. You’re Meryl Streep slipping into a role. Your creative inner mind will be alongside your conscious mind, enjoying the flow as you engage with your daughter and your grandchildren in fun ways, and every time you enter that stage, that family stage, you’ll find yourself expanding into your new role in satisfying ways, sometimes surprising yourself, always enjoying your secret strategy. It’s OK to let your husband in on it. Afterward, you and your husband may chuckle about the relaxed grandmother character you’ve created. You’re both director and actor on this stage. Really enjoy surprising them.”
She came out of her trance and exclaimed: “I can do that!” After some additional mental rehearsal, she left in a very good mood. Three days later, my phone rang: “This is Meryl Streep calling. I just earned an Oscar. I spent a whole day with Emmy and her family, and at the end of the day, my husband asked Emmy, “How did your mother do today?” Emmy said: “She did great!”
It was their first pleasant, relaxed day together in many years, a day without tension and conflict. I asked Debbie what she found interesting while playing her new role. She replied, “I felt so calm–very different–calm and comfortable.” ;
A well-deserved Oscar!
A few weeks later, she called to say, “I’m so excited and happy because I entertained my entire high-stress clan, and did my Streep thing, and enjoyed myself!”
A couple of months later, she said, “I’m so glad I did it. Strangely, now I feel more motherly and understanding toward my daughter than ever.”
By Steve Andreas
This is a really lovely example of many different important aspects of change work, and the importance of a careful choice of words.
The first session doesn’t offer a clear direction for intervention, so Ronald Soderquist wisely brings in the daughter, so he can observe them interacting, rather than knowing the daughter only through the filter of the mother’s perceptions and report. Although the interaction becomes much clearer when the daughter joins the mother for the second session, having them both together makes it difficult to intervene usefully.
In that session, it becomes clear that, for both of them, the issue is one of identity, in contrast to behavior. Both want the other to change, and each speaks of this change in terms of being different–in contrast to acting different. The daughter says, “Why can’t you be like other grandmothers,” and the mother says, “Why can’t you be more organized and quiet.” (Most answers to either of those questions would lead only to justifications and rationalizations, neither of which would be useful.)
For most people, being different seems to be much more difficult than doing something different. If you describe a certain behavior as “being different,” most clients will object, as both mother and daughter do in this case, and this is one source of what many therapists describe as “resistance.”
As long as both mother and daughter think of their differences in terms of the other having to be different, not much is possible. Demanding that someone else be different is an ill-formed outcome that gets many of us stuck and frustrated, because while you have at least some choice about your own behavior, you really don’t have any choice about what someone else does. That’s why having them “listen nonjudgmentally to each other” in the second session went nowhere, despite how useful that intervention often is.
But if you describe the same behavior as “doing something different” or “acting different” a client will often be willing to consider it. This distinction between identity and behavior is one that many therapists have never learned, and it’s often a crucially important reframe. In this case, it’s the key understanding that allows the mother to change her behavior and have a new internal response to the chaos of her daughter’s household.
In the third session, the mother states even more blatantly that her understanding of the issue involves her identity, “It just isn’t me to be like other grandmothers. . . . I like me the way I am. She’s asking me to be someone I’m not.” That brief utterance makes six references to her identity and five to her being: isn’t, me, be, I, me, I, am, me, be, I’m.
Soderquist begins his intervention by exquisitely pacing her focus on her identity, assuring her, “You’re fine just as you are,” relieving her of any pressure to change who she is, and implying that her daughter’s attempt to change her isn’t valid. He follows this up immediately with saying, “And Emmy is fine the way she is,” which implies that the mother’s attempts to change her daughter are just as invalid. Since the mother already agrees with the first statement, she has to agree with the second, which only reverses the direction of the logic. Abandoning her attempts to get her daughter to be different closes a door that leads nowhere, and opens a door to a more useful alternative.
To strengthen this understanding, Soderquist first offers a generalization about two of them being different. “You just happen to be very different personalities.” Then he follows this up with two metaphors that express this difference in who they are, “She’s AM, and you’re FM: she’s rock-and-roll, and you’re chamber music.” Both metaphors are drawn from contexts in which differences clearly don’t need to change.
He begins his description of Meryl Streep, and the difference between her self and the roles she plays, with the word, “Fortunately,” a cognitive qualifier that creates an expectation of good things to come. If he’d used a different adverb, such as “unfortunately” or “sadly,” the mother would have had a very different expectation about what he’d say next. Saying “there’s a solution,” further directs her attention away from the problem and builds even more positive expectation.
“I wonder if you’d enjoy inventing a role that works well when you’re with Emmy and her family,” is called an embedded question, a hypnotic linguistic form often used by Virginia Satir, one of the greatest therapists who ever lived. Although it’s a statement, it elicits an internal response as if it were a gentle question, but without demanding an overt response the way most questions do. This invites the mother to consider changing her behavior without any demand that she do so, and with no need to respond verbally.
Notice how different an overt question with the same content would be. “Would you enjoy inventing a role that works well when you’re with Emmy and her family?” would demand a verbal answer, and keep her externally focused on Soderquist, making it harder to turn inward and consider whether she could enjoy doing that. The embedded question focuses her attention on whether she’d enjoy playing a role, implying that she can do it; the question is merely whether she’d enjoy it or not. Before, she demanded that the daughter change; now she’s invited to change her own behavior (while keeping her identity intact)–an enormous shift in attitude that most clients can benefit from.
As she begins to consider this possibility, she’ll naturally become more internal, a perfect time for Soderquist to slow his voice to be more hypnotic and set up the specific cues for her new role play–all in present tense, so that she can rehearse it as if it’s happening at the moment. “When you open the door to her home, you can see it like a stage. You pause at the door, view the scattered toys, and listen to the active children as part of a stage set.”
Then he permissively suggests a response she might have, “You may find it amusing,” and follows with even more detailed suggestions that continue to encourage a rehearsal of new behaviors. “You’re Meryl Streep slipping into a role.” The use of “slipping” implies that it will be easy and effortless. Think how different it would be for her if he’d said “trying to get into role” or “struggling to act differently”! He then goes on to suggest other behaviors, and possible pleasurable responses for her.
When he says, “Your creative inner mind will be alongside your conscious mind,” it implies that the creative mind is unconscious and will assist her. As he goes on to say, “enjoying the flow as you engage with your daughter and your grandchildren in fun ways,” it implies that much of this will occur unconsciously and spontaneously. Notice all the words that make this rehearsal an enticing prospect: enjoying, flow, engage, fun, expanding, satisfying, surprising, enjoying, secret.
A bit later, when Soderquist says, “Afterward, you and your husband may chuckle about the relaxed grandmother character you’ve created,” it invites her to take a future vantage point and look back on what she’s imagined, as if it had already happened, further cementing its reality as something she can do. With all this elegant hypnotic language, it’s not surprising that when she emerges from her trance, she says, “I can do that!”
This entire intervention probably took less than four minutes, showing that when you know what to do–and how to do it–change is easy.
I think Ronald Soderquist deserves an Oscar, too!
Ronald Soderquist, Ph.D., a hypnotherapist and licensed Marriage and Family Therapist, is the director of Westlake Hypnosis in the Los Angeles area. He’s served on the staff of California Lutheran University and other universities and graduate schools. Contact: email@example.com.
Steve Andreas, M.A., has been learning, teaching, and developing personal-change methods for more than 53 years. His books include Virginia Satir: The Patterns of Her Magic; Transforming Your Self; and Six Blind Elephants: Understanding Ourselves and Each Other. His new book is Transforming Negative Self-Talk: Practical, Effective Exercises. Contact: firstname.lastname@example.org.
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