My “Best Practices” in Psychotherapy: Part II

Techniques: Weaving and Blending Surface and Depth

I have found it a powerful combination to utilize both pointing out and working with surface behaviors as they occur and alternatively, interpreting unconscious dynamics as appropriate. The surface—what is happening in the present as the patient presents themself—blended with making conscious what has been unconscious, may work in tandem to increase awareness of what they are doing and how they are doing it, along with how they are being influenced or even controlled by what is outside of awareness. For example, helping an adult realize how unconscious resentment toward a parent for an incident that took place years ago continues to shape his thinking and behavior toward that parent can be an illuminating insight that frees up negative emotion and cognitive rumination.

I conceptualize the work as pointing out what is on the surface and probing it to go deeper into what is outside awareness combined with examining the past and making unconscious interpretations that move depth to the surface. I focus on the process by pointing out the surface as it unfolds and content, by probing stories and details, finding their meaning.

The theoretical models deeply embedded in my work include existential-humanistic with emphasis in Gestalt Therapy, Psychodynamic, and life-long exploration of various Eastern philosophies and meditative practices. “Lifelong” means going back as far as high school, when I was using mala beads and chanting with a group in the Nichiren sect of Buddhism.

Undervaluing Past Experiences

In the early years of practice, I noticed how many clients did not value the impact of their past experience-even traumatic experience— on their present behavior and the issues that they were presenting. They had trouble seeing any relationship between their past and present difficulties. At first, I attributed this to their lack of psychological knowledge. Later, I revised my thinking to include not only a lack of knowledge but also the resistance to accept that they could possibly be so heavily influenced by events in the past. Some clients held an overly optimistic view of their ability to purposely choose to act unencumbered by past trauma. While certain adaptive defenses blot out some of the past and may be useful in allowing the person to move forward in life and not become fixated on past negative events, this does not mean these events don’t continue to have an impact, whether they are aware of them or not. Their defenses are continuing to influence their thinking, emotional reactions, and decision-making.

By undervaluing past experiences, some individuals prefer to look for current, short-term causes to their problems and instead need to understand how their current and long-term challenges have been conditioned by earlier relationships and events. This realization of connecting their past to their present is typically an “ah-ha!” insight moment, in which they finally see whythey have been unable to let go of their negative programs. It is said that becoming more psychologically minded by connecting past to present is one of the primary self-growth goals for everyone—not just those in treatment.

The Unconscious Mind

Some patients, even those with some psychology background, do not understand or honor the power of unconscious dynamics influencing their conscious thinking and behavior. In addition, it is my belief that for many clinicians who do not receive specialized training beyond their academic classes and clinical internships, psychotherapy training no longer focuses on unconscious dynamics as it did in previous generations when its influence was more mainstream. While cognitive-behavior theory understands the importance of identifying and altering internal dialogue, it does not go far enough in helping patients understand how they may be motivated by deeper psychic forces of which they are totally unaware.

Whether it be psychological or spiritual growth, one of the best metaphors to describe this experience is that of “waking up.” Waking up from what is unconscious to the light of consciousness and waking up to parts of ourselves that transcend our ego identifications, beliefs, and the body. We wake up to a higher level of consciousness, always from the slumber of what is unknown to what is now known.

At a certain level of having awoken, we say someone is “enlightened.” Socio-cultural history provides us with numerous examples of how even enlightened beings typically continue to be dragged down by unconscious or conscious, uncontrolled aspects of themselves that are not fully integrated, and may interfere with putting their best teaching foot forward. If this were not so, we likely would not hear the far too frequent cautionary stories of gurus, priests, and teachers from all religions and philosophies taking advantage of their authority or abusing their students.

As a clinician, I have come to the understanding that no one wants to believe that the motivation for their behavior may be out of their conscious awareness and control.

Because of this, it goes against the grain for some to accept the notion of an “unconscious mind.” Accepting the power of unconscious motivation is one sign during treatment that a patient is growing in their psychological self-knowledge. It may also help them understand and be more sympathetic to others’ behavior. For example, if you can accept that your sister does not necessarily remember or cannot identify her resentments from growing up together, it is easier to take the burden of blame off her today and see that she is not purposely trying to emotionally injure you. She is simply reacting to you on “auto-pilot” today as she may have long ago, and you may be doing the same with her.

One way the unconscious motivation may be revealed is through strong emotional reactions. As a “best practice,” whenever you observe a patient expressing a clearly out-of-proportion reaction, you want to ask, “Where do you think that emotion is coming from?”

For example, a woman in her 40’s tells me she sees signs of hair loss and is taking a product to address the problem. She laments, “This morning, I stared  in the mirror and began crying. I looked hideous. All I see now is my hair, skin and body beginning to fall apart. I couldn’t stop crying. I felt such a strong reaction,as if someone had died.” I respond, “Yes, that’s a strong reaction.” I pause, look her in the eyes, and gently ask, “Who died?”  She is startled by my question. Then after a half-minute of deliberation, she answers, “You know, what died is the part of me that has always felt that my body, my looks, were what I had to offer and now, I’m losing it.” This led to a productive dialogue on how she was always told by her mother that her physical beauty was her primary asset.

In working with the unconscious, I have found there are two obvious obstacles that must be confronted:

 1. Patients must understand and accept that they may be motivated by events and reactions of which they are unaware

2. Have them accept the specific interpretation presented when it is totally dependent on the knowledge and ability of the psychotherapist to bridge the gap between unconscious and conscious behavior.

This requires knowing the patient’s history and defenses well enough to connect past to present. The interpretation is presented as a possibility, not as a certainty, even when I may be certain.

For example, I may say, “Do you think your unwillingness to speak to your mother for the last month may be related to your anger at her when she forgot your anniversary?” The patient makes the decision to accept or reject the interpretation. To be accepted, it must, at some point, resonate with the patient. Sometimes patients will have a knee-jerk reaction to reject, however, after allowing time for consideration and softening, they later report resonating with the suggestion I provided. Those who stay in treatment develop the ability to ask, first, “What is my motivation for my behavior?” and, later, “What may be myunconscious motivation for this decision?”

Working with Unconscious Interpretation

An interpretation of the unconscious may be followed by having the patient express whatever the mental or emotional material may be. Using resentment as an example, a patient may speak to me directly as their parent or perhaps in an “empty chair” dialogue, in which they switch roles back and forth with the parent. If the patient chooses, and with sufficient preparation, they may talk to the parent directly. This is an option the patient needs to prepare and feel ready for, not something that I expect of them or push them to execute. I notice this usually takes them weeks to months before they feel ready to face a parent if they decide to go this route.

I have observed over the decades that those who choose to speak directly to their parent, sibling, friend or lover about their current or past feeling tend to experience a more complete resolution. In my opinion, speaking directly means having an in-person meeting with the individual and the patient. It does not mean communicating by text, email, or phone. Since part of the reluctance to expressing emotion is the fear of the other’s response, I want them to see that they can face the other directly and handle whatever reaction they may receive without it having to threaten the relationship. If it is not possible to speak to the person directly because they may no longer be living or it is not safe to meet with them, I have them express their feelings to me as a substitute for the person in question.

Defense Mechanisms

While the purpose of treatment is not ostensibly to teach patients psychology, in my experience, that is what indirectly takes place in the service of understanding their behavior. What is projection? What is rationalization? Or retroflection? A quick perusal of online lists of primary mechanisms confirms that retroflection is a defense not typically listed. But it is considered significant in Gestalt therapy. Those who have a basic understanding of various defense mechanisms are armed with an advantage to gain insight into themselves and others. Ideally, patients become curious about defense mechanisms and do some research on their own.

Addressing Here-and-Now Behavior

One tool I have found effective in the early sessions and as an ongoing tool throughout treatment is pointing out something in the here and now that gives some insight into their self-presentation. I do this partly to capture their interest and show them that I can offer them something of value in the early sessions without having to know them well. I also do it because I know that in the early phase of treatment, patients are more open to my statements. The freshness of our interaction heightens their receptivity to any comments I may make. I take advantage of this novelty phase of the relationship by making observations and/or interpretations that have a higher chance of making an impact and being remembered. Examples of observations include:

• “I notice each time you mention your husband, you tighten your lips. What are you feeling when you think of him?”

• “Are you aware that you’re smiling while talking about your mother’s cancer? How does your smile relate to her disease?”

• “I see you grimacing as you tell me about your lack of sexual interest in your wife.”

• “You are avoiding eye contact with me now. What do you think makes it difficult to look at me?”

• “I notice your voice goes down when you mention your new boss. How do you feel about her?”

Having been steeped in Gestalt therapy training and practice long ago, it has become second nature for me to make comments on behavior being presented as we interact. For most patients, it is not the norm in their everyday life for someone to point out what they are seeing and hearing as it is happening. Nor is this a common tool for most psychotherapists to learn in their clinical training. But in my opinion, it is one of the most powerful and penetrating “best practice” tools a psychotherapist has available.

One way to work with what is pointed out on the surface is to ask the patient to keep doing what they are doing or even exaggerate what they are doing. This helps connect the behavior to the emotion that accompanies it. For example, “Could you tighten your lips even more? What do you feel when you tighten?”  Other examples of commenting on what the patient is doing include:

• “I noticed you were just talking about your disappointment with your son and then shifted to your wife. What made you think of her right then?” Or: “ What were you feeling about your son when you shifted to your wife?”

• “You are opening and closing your hand in a fist. Is there someone you’d like to hit?”

• “You keep glancing at the clock. Are you anxious for the session to end?”

• “Your voice just lowered when you mentioned your girlfriend’s handling of her finances. What would you like to say to her about it?”

One of my tasks is to discern which behaviors being displayed are deserving of being called out. This means I need to believe it is worth our time to focus on the surface and process because it will take the patient deeper into cognitive or emotional understanding. In essence, I use the surface as the gateway to deeper insight.

Truth-Telling

Patients are paying for and deserve the truth about what I think is happening. I give my opinion sooner and more directly than many others might. This means believing that ultimately, they can handle hearing the truth, as well as believing that the truth paves the way toward greater integrity. I was told early in my graduate training by a psychoanalyst something to the effect of, “patients can handle hearing more than you think they can. Their defenses will protect them from what they aren’t ready to hear. Act as if this is true.” I have this in the back of my mind when I consider what someone is ready to hear. If I assess that they have the ego strength to handle hearing something they may not like and we have developed a level of trust, I take the slight risk to present it to them.

For those psychotherapists in the early phases of building a practice, it is easy to be overly careful about saying anything that may upset patients and make them terminate treatment, even when it may be just what the patient needs to hear. They may be focused on the threat of loss of income and may not take risks that could upset the patient. While this is a normal cautionary reaction while building a practice, it can be at odds with doing your best work through taking chances. “Best practice” is to resist the temptation to be overly careful and conservative in experimenting, keeping in mind you are bounded by good professional and ethical practice.

One truth that most psychotherapists learn along the way is that patients will purposely and unconsciously lie to them. They will deliberately withhold or “forget” crucial pieces of information that would give a more accurate and complete clinical picture. And when asked, “Are you telling me the whole story?”, they will assure you they are, when, of course, they are not. They are lying about not lying. Sometimes they come in the next session and tell me they withheld. They fear being judged or disliked by me, which is how they are feeling about themselves. I handle the revelation of withheld information by asking, “What did you imagine would happen if you told me that?” Confronting lying may lead to a discussion about other areas and facts of their life they are lying about out of fear, shame, embarrassment, or to impress the other.

Asking Good Questions

A “best practice” is to learn how to ask good questions. Good questions keep the flow of the session moving, take the dialogue deeper, and immediately get the interest of the patient. They are often met with the immediate response of, “That’s a good question.” This means, “I haven’t thought about that before and have no easy answer but see how it’s relevant to our topic.” Good questions may also take the patient deeper into connecting various elements that may not initially seem relevant. It is easier to ask good questions when you know the patient well and can connect elements yourself that the patient has not yet realized. Your questions may help them make those connections.

Having a Sharp Memory

Besides an unconscious insight that brings an “aha” moment, I believe the most impressive feat from the patient’s point of view is their therapist’s ability to remember their history in detail. It shows them in no uncertain terms that you have listened well enough to their history to remember it accurately. It also demonstrates your ability to recall it in the moment, helping them connect past to present. If you can combine asking good questions with a sharp memory, you will gain the trust of patients, as  likely, they will not be used to anyone listening to them so closely.

Being Comfortable with Silence

I believe one of the skills that differentiates an experienced and skilled psychotherapist from one that is not is the ability to allow empty spaces or pauses, in the dialogue without filling them. There are crucial moments when it is important for the patient to reflect on what they or the therapist has just said. These spaces are often filled with internal dialogue, imagery, or emotion by the patient. What I call “pregnant pauses” allow room for internal reflection, rather than quickly moving on. The therapist needs to allow these spaces and understand they are necessary for the patient to have to integrate the material being discussed.

One of the values of meditative practice by the therapist is that it makes them more comfortable with these silences. Sometimes there is a natural break in the dialogue because a topic has been exhausted. I am silent during these times, comfortable in waiting for the patient to begin again when ready. One way to practice staying silent outside the consulting room is simply noticing in conversations the pauses, sitting with them, and not feeling compelled to say anything. I believe “best practice” is to resist the temptation to fill the empty spaces with words to save the patient and yourself from a moment of awkward discomfort.

Laughter as Connection

Much of what transpires in the consulting room is heavy in content and serious in tone. When natural moments of lightness result in laughter, it helps connect the patient and the therapist. I view these moments as a “meeting of the emotions,” in which we can view something as humorous and respond to it together. Pay attention to those patients who are never able to find humor in anything they say, or you may say. Sometimes, in a moment of shared humor and laughter, truisms arise that may only be acceptable if they are followed by laughter. While all psychotherapists are taught how to bracket their own emotions when accompanying the patient into the depths of pain and suffering, some are not taught how to find the meaning that is possible in a moment of shared laughter.

Sharing Personal Information

Disclosure may be conditioned by one’s theoretical orientation. From the existential-humanistic perspective, some sharing of personal information by the therapist is viewed as positive to building a solid bond (Bracke, & Bugental, 2002; Mahrer,. 1978). It is also in line with the “I-Thou” relationship, in which both people meet each other authentically (Katz,1975; Kramer, 2003). I will share something personal only when it is clear to me that the patient can learn from hearing my experience by gaining a different perspective or reinforcing their own. I never share any personal problems, as I am there for the patient, not for them to hear about how I may have the same or related issue. My sharing is circumscribed to things like, “Be sure to take the train to Lake Como when you’re in Milan” or “Try Nick’s Swedish-style Light Ice Cream if you want one that is lower in sugar and tastes good.” Refrain from ever burdening patients with your own personal issues. When you work with some patients over years, it is unavoidable that they will learn certain facts of your life just from observation and inference. If in doubt, it is usually better to refrain from sharing any personal information that could elicit envy or negative self-evaluation by patients.

Summary

In summary, I have offered some of my “best practices” in psychotherapy. All of these are worthy of more in-depth attention. My intent was only to identify them with a short description and examples. My hope is that you will find them worthy of your consideration and incorporate those that are consistent with your own theoretical orientation, patient population, and style of practice.

Steven Hendlin, Ph.D., is in independent practice in Newport Beach, California.