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Part II, A Practical Guide

Next: Part III A Clinical Matrix

In This Section:

Why a hypothesis?

Seeking truth in an uncertain world

Knowing the answer and finding the question

Three "tricks"

Testing, testing, testing




Chapter 4: Developing a Hypothesis I, Overview

In the last chapter about the Classic Session, I described how free flowing conversation naturally leads to the empathic understanding that is the key to cathartic healing. This is true, but remember that there is another change process, internalization. In psychotherapy, the two work very differently. Catharsis is self-propelled if you let it happen. Changing people's internalized attitudes and values is a far more laborious process that taxes the energy and motivation of both patient and therapist. For many reasons, but especially this part of the work, it is very helpful to have a working hypothesis, your best explanation of what is going on. Your understanding will give focus and direction to the work as well as predictions that can be tested and that will mark your progress along the way to a clear goal.

A Scientific Spirit

Science is about discovering what is demonstrably true, independent of people's assumptions and biases. Psychotherapy, psychodynamic or cognitive, works on the principle that entrenched dysfunctional patterns of reaction are based on misunderstandings and distortions of reality. Facing the truth allows us to grieve for and let go of the illusions and distortions that may once have sustained us, but ultimately cost much too much. Therefore, seeking a true understanding is central to the effectiveness psychotherapy. In fact, it has often been observed that therapy built on an incorrect understanding simply doesn't work.

How can we maintain a scientific spirit where there is so much subjectivity and where each therapy is so unique? Statistics and rating scales can only cover the grossest aspects of what we do. The answer is to build and test hypotheses as we go. As in any scientific activity, carrying a working hypothesis makes us more sensitive to the data we encounter. However, hypotheses can be wrong. They must be held with a light touch. We must be willing and ready to recognize when the hypothesis isn't holding up and it is time to go "back to the drawing board."

Reverse Engineering

Reverse engineering could be defined as looking at a solution in order to understand the problem it was intended to solve. This is exactly what we do when we construct a working hypothesis in psychotherapy. Reverse engineering is actually a very creative activity. You are inventing likely explanations, then testing them, first mentally, then in practice. As in any science, a good theory or hypothesis is one that has elegance, meaning that it satisfies all the data in the simplest, neatest way, and hopefully leads to further clarifications and questions you hadn't expected.

Three "Tricks" to Simplify the Task

Given the infinite complexity of the human mind, we need some tricks to simplify the task of reverse engineering. I will suggest three.

1. One Main Issue: First, it is very helpful to make the following assumption: People's problems revolve around one main issue. I can't guarantee that this is always true, but in practice it is largely true. This is similar to the observation that the mind has one emotional cursor. I believe the reason this assumption works is that the mind tends to organize itself around one emotional focus. Any new emotional issues tend to be organized according to what is already there. In any case, making this assumption will force you to organize all the things you learn about your patient around one central focus. There will be one main goal, one main source of motivation and energy, and one main set of resistances to achieving the goal.

2. Logic by Elimination: The second "trick" is to reason by the process of elimination. In order to do so, one must first have a list of all the possibilities. You can never be completely certain that you have covered all possibilities, but it is surprisingly easy to come close to a complete matrix of possible explanations for a given observation. Following the "Practical Guide" that comes next, I will share with you my personal "clinical matrix" of categories from which my hypotheses almost always flow.

3. Ask the Patient: The third "trick" is to ask the patient. It is often worthwhile to ask the patient for his or her private hypothesis about how to explain things. The question will probably surprise the patient and will give you good data if not the full answer.

Testing Your Hypotheses

There is still a lot of uncertainty to a hypothesis, so before you begin to imagine that yours might be true, it must be subjected to rigorous testing. You should critique your own hypothesis vigorously, looking for data that contradicts it and other possibilities that you hadn't thought of. If it survives that test, you may share it with your patient. The best time to do so is when there is resistance and a metacommunication is needed to get you unstuck. This is called "making an interpretation." Your patient's reaction will very likely give you more data. If there is no special reaction, then either you have missed the mark or the material is still buried deep. If the patient reacts strongly but negatively, you have a new question to ask. "Why such a strong reaction?" Maybe this means you were on target, but it could also be that your idea is wrong. In any case, the patient's strong reaction gives you more unanswered questions and more data to work with. The final test is the test of time. Ideas that are off the mark usually don't generate more thought or feeling. They fade away and leave you where you were before.

Part II: Practical Guide