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In This Chapter:

The magic bullet

Curiosity, your best guide

Spiral Organization of the session

Resistance: How to recognize it and what to do

The "Three Step" dance

Chapter 3: The Classic Session

Let us start with an uncluttered picture of the basic open-ended, free-flowing dynamic psychotherapy session. This modality is chosen as a basis for further discussion because it is inherently flexible. Less brittle than psychoanalysis or cognitive-behavioral therapy, it can be modified without taking away from it's essential quality. This form of "talk therapy" builds naturally from ordinary conversation, and can be recognized as the starting point for most real-world therapy.

The patient has come to the session for one reason, to feel better. Your recognition of this fact and attentiveness to the patient's need will be the key to his or her cooperation and active participation in the process. Even if your goal is different, say, to gather information, you be more efficient if you pay attention to helping the patient to feel better.

What makes people feel better?

Let's look at three "medicines" that we instinctively use to make people feel better. The first, Reassurance, works, but has side effects. In your efforts to reassure, you may tell the patient things that don't turn out to be true. This will cost you much more later. Even worse, the patient probably hasn't told you what is really worrying him or her. Your reassurance will seem superficial and unhelpful. Next, advice giving may also make the patient feel better by giving more of a sense of control. Again, the same side-effects. Your advice may turn out to be unhelpful, and may miss the most serious concerns that haven't been stated. There is a new problem as well: The patient may have an unconscious need to fail or to show that you are wrong. The patient may misinterpret or misapply your advice and create a bigger problem.

The third "medicine" is truly the magic bullet. It has no dose limit, no side effects and is amazingly effective. This medicine is empathic understanding. I don't mean solicitous talk, I mean creating an atmosphere where the patient tells you about his or her experience in enough concrete detail so that both of you feel the emotions. Empathy is not something you do, it is something that happens when you create the right conditions for emotional activation and communication.

The unique organization of the classic interview

In every other type of medical interview, the doctor has the roadmap. The interview is aimed at navigating through a pre-existing decision tree. In the free-form psychotherapeutic interview, the patient has the roadmap, but it is mostly unconscious, so both of you have to discover it. What makes this happen is the combination of the patient's drive to feel better and your demonstrated willingness to listen.

The psychotherapeutic interview starts with what the patient has most on his or her mind. In the beginning of therapy, this is what is known in medicine as the "chief complaint." This is the problem or issue that causes the need to feel better. It is the engine that drives the interview, so the interview should focus on this point till it is thoroughly and empathically understood.

In later sessions, it helps to think of the mind as having a "cursor," an arrow that points to the one place where the patient's concerns are centered. Consciousness can hold more than one thing at once, but only one is the immediate emotional focus. Thus it is "what the patient has "on her mind." The chief complaint, therefore, forms the center of the spiraling interview. Your job is to follow the emotional cursor at all times starting at the beginning of the session. This means listening with a "third ear" to the first things the patient says until it begins to be clear where the cursor is pointing.

The Question

Traditional teaching says there are "closed-ended" and "open-ended" questions. Actually there are infinite shades of gray, and several key dimensions to any question. Think of all the possible things a patient might say in geometric terms as a plane with an infinite number of points. The most challenging question you could ask is silence. Assuming that the patient understands his or her job to speak, then silence is a request to choose anything at all to say. This is the most open-ended of all questions and the most difficult. Thus, when you actually verbalize a question, you are, in effect, narrowing the field of possibilities.

Questions can be wide or narrow. Too wide is frightening, and too narrow feels confining. They can be more abstract or more concrete. Abstract may leave more room: "Tell me about yourself," vs. "How do you spend your day?" People with more education are often more comfortable with abstract questions, while others may respond better to concrete questions. On the other hand, abstract questions can invite intellectualization. Feelilng is usually attached to the concrete, and abstraction can remove feeling. "How do you feel about..." is much more likely to elicit an abstract, unfeeling answer than the concrete, "How did you take it when..." Above all, your questions reveal how well you are listening, and tell the patient whether it is safe to reveal more.

Following Leads

Your ability to follow the patient's leads is his or her indication that you are "on board." A "lead" is anything unexpected coming from the patient. For the most part, you will do better if you allow your native social skills to guide you, as opposed to rules or set scripts. The key to social conversation is curiosity. Your curiosity will naturally point you to both the overt leads, and the unexpected gaps where something is left out. What results is like social conversation except that, as a therapist, you have an implied mandate to be more probing than you would otherwise. You can and should seek to satisfy your curiosity.

The Therapist as "Shepherd of Resistance"

As long as the patient's conversation is flowing you should stay quiet and not intervene. How can you tell it is flowing well? There are two indications. First, your understanding will be growing steadily. You will be learning new things about the patient's life. Second, and most important, what you learn will be crystal clear. This quality in the material you get is what allows empathy. When words don't convey crystal clarity, then you will be losing the trail of empathy. You will have lost your sight of the patient's mental cursor. If either indicator is lost, growing understanding or crystal clarity, then you can say to yourself that you have hit resistance.

Resistance is never conscious or willful. When lay people hear the word, they think of conscious, willful resistance. But therapists always mean the kind that happens automatically without conscious purpose. Occasionally what looks like resistance can be the result of a misunderstanding. Perhaps you didn't explain well what you expected. If the patient doesn't understand or misunderstands what is expected. It is your job to clarify.

Now that the stream of crystal clear information has dried up, we know we are dealing with resistance. Since the patient is not expected to be aware of resistance without you pointing it out, then you, the therapist, must carry the burden of guiding the patient to resolution of resistance. In fact, resistance is the therapist's primary job. The classic theory of dynamic psychotherapy is that all that is necessary for the therapy to succeed, is the resolution of resistance. This will lead to understanding the patient's problems and the patient will be cured.

A Three Step Dance: Nudge, Metacommunication, Tactical Retreat

This simple three-step formula will be sufficient to guide your interventions from here on. When information is flowing without resistance, you don't have to do anything. In fact, most things you might say or do will actually distract and disrupt the flow of material. That is why we call the things you do, "interventions." They are inherently disruptive and should only be used when there is a positive need. When you encounter resistance and must intervene:

Step 1: First a gentle "nudge" will test to see if the resistance is a significant one. "I'm not quite clear about that." is an example. A nudge is some small, unobtrusive indication that you expect more from the patient. If it works to get the flow going again, then you can conclude that the resistance was not a significant one. You will not have disrupted the session and you will be back on track, listening and receiving more crystal clear communication.

Step 2: If your nudge doesn't work it means that the resistance is significant and must be dealt with. The flow has already been disrupted, so an intervention will not distract. At this point, beginners try to fight the resistance. They may speak like a district attorney or try to overcome resistance by sugar coating their questions. Patients know immediately when you are trying to bypass their (unconscious, non-wilful) efforts to fend you off. They will close the door firmly. The only thing that will work is for you to shift the focus to the communication rather than the content. This is appropriate because the emotional cursor has already shifted. The patient's concern is the struggle over whether or not to reveal. Your intervention will be a metacommunication, that is a communication about the communication. You have shifted the topic 90 degrees from the previous direction of the session. Feeling that you are really following his or her concerns, the patient will accept this, and will be quite willing to join with you in addressing the communication problem. You are right in line with the patient's emotional cursor.

Your metacommunication, for example "It seems to be hard to talk about your mother's death." will very likely release the resistance. It may take some more exploration, but your new focus will usually work to help the patient get unstuck. As you understand the resistance, you will be using empathic listening to heal the feeling that has been causing the trouble. As the pain or anxiety is relieved through cathartic healing, the patient will usually be able to continue. It is possible that the session will have taken a new direction, but it will again be flowing in a natural way, and you will be receiving crystal clear communication anew.

Step 3. In case the metacommunication doesn't work, and the patient remains stuck, it is time for a tactical retreat. Tactical means that you tell the patient overtly that you haven't given up. You will come back to this difficult material at some future time, but for now, you give the patient permission to let the subject go. "I guess this is really hard material. We can come back to it some time later." The promise to come back later leaves the patient with hope, and removes demands that the patient cannot meet. The session will make a new start in some other direction, and will soon be back to new, crystal clear material. It is important for you not to forget to come back to the material you have deferred. Your failure to do so will eventually be interpreted as a lack of interest.

That is it. Following this simple three-step dance will give you a patient who feels better and a growing understanding. That is 90% of what therapy is about. The following chapters will focus on the remaining 10%.