Show or Tell: Therapeutic Communication as Theater By Michael Karson on 10/24/19 - 12:57 PM

An intern said to me, “You always stress the importance of getting examples. I’m seeing a young woman who complains of anxiety, but she won’t or can’t give examples. She will say only that it happens often, and when I ask what happens, she’ll only say anxiety.”

There are three ways that patients communicate with therapists: journalism, poetry and theater. Journalism involves reporting information. Journalism is often used to block relational bonds by filling the space with speech that is not designed for or responsive to the particular relationship. Journalism often strengthens the professional aspect of the relationship (like reporting symptoms to a doctor) at the expense of the therapeutic aspects of the relationship (which involves revealing oneself without too much cognitive packaging). A certain amount of journalism is needed in the initial professional frame to decide if the dyad will venture into the therapeutic frame.

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Poetry, often the result of free association, or telling a story or stray thought without really knowing why, has metaphorical elements. The therapist wonders why, of all the millions of things the patient could have said at that moment, they picked this one, and the answer usually involves some aspect of the immediate environment reminding the patient of some aspect of the story. For example, the intern’s patient might have said, “Well, one time I felt anxious was when I was going to the dentist for a checkup. I wasn’t afraid of physical pain or anything. I was afraid I was going to get berated for not flossing often enough.” The therapist could now consider this story as a metaphor for the patient’s experience of the therapist. Was he asking her to open her mouth to find out what she has been doing wrong so he could blame her for her own troubles? Had he already done something like that? If so, he will need to process that exchange with her before she could be expected to treat his inquiries as welcoming and curious.

Theater refers to communication that is shown rather than told to the therapist. It’s often a form of projective identification, where the patient shows the therapist what they’re feeling by getting the therapist to feel it instead. That’s not intentional, of course; it’s a function of the way feelings are often expressed in behavioral patterns , such as bullying and intimidation. If a patient wants to avoid feeling intimidated, it may be that the only counterpoint they know to intimidation is bullying, so they bully the therapist, who then feels intimidated. Theatrical communication also stems from the general principle that the variables that control behavior in one situation are often the same ones that control it in another. Communication within therapy is often ambiguous, which can encourage this phenomenon. My view is that good therapy depends on the observation that patients mess up therapy relationships in the same ways they mess up other relationships.

In the intern’s case, the patient is enacting something about her anxiety by refusing to explore it. The therapist might say something along the lines of, “Walking through life feeling uneasy with no recollections, no images of what dangers lurk and no reminiscences about what happened in similar situations in the past—walking through life with earplugs and a blindfold and distracting sounds—that sounds nerve-wracking.” The therapist might suggest working first on what’s so dangerous about letting the imagination wander.

Another patient sought therapy because he realized that he doesn’t have any real friends, only what he called acquaintances. The therapist invited him to consider which person among his acquaintances would be most likely to become a friend, so they could explore what keeps him from making friendly moves in a specific context. The patient insisted that none of his current acquaintances could become friends, so the dyad discussed abstract situations and hypothetical friends. The therapist might have said something like, “I wonder if what’s keeping you from playing along with me keeps you from playing along with others?” This would have been based on the idea that the refusal to name a specific acquaintance as a potential friend was not journalism about the people in his life, but a theatrical communication about what gets in his way.

A narcissistic man started therapy only after reading a great deal about therapy in technical books typically written for therapists. Everything his new therapist said or did was subjected to scrutiny and critique. For instance, the therapist asked him for examples of his presenting problem—repeated disappointment by his friends and family. He cited the extensive literature on the disadvantages of asking questions compared to making observations and I-statements. The therapist treated this at first as journalism, information about his extensive knowledge of therapy, but when he said that the therapist’s looking flustered made him angry, she interpreted it as an effort to intimidate her. He might not have been a good therapeutic fit for this particular therapist, but it might have helped to view his performance as a form of theater. “It seems like you’re showing me what it’s like to be constantly appraised and constantly criticized.” The idea would be to make him feel understood and, just as importantly, to show him that there may be a way for them to relate to each other as teammates rather than as judge and contestant. It might turn out that he is used to relating to others only as an object of scorn or as an object of admiration, and they might have developed a therapeutic contract around relating to each other differently.

Family therapists developed the technique of enactment. Instead of just talking about marital fights or efforts to discipline a child, the therapist asks the couple to fight about something or asks the child to misbehave so the parents can discipline her right there in the therapy office. This allows for real-time intervention in the problematic ways of relating. It also shows the couple or the family that fighting and misbehaving are more under their control and more tolerable than they might think. The essential idea behind relational therapy is that the patient is already performing enactments. The therapist has to be open to construing annoying patient behaviors as a kind of communication to capitalize on this idea.

As professional clinicians, we are often well-prepared to engage in journalistic communication with patients about their symptoms and situations. As therapists, we are often well-prepared to listen for metaphors that express patients’ psychological patterns or their experiences of us. Some communications from patients are disruptive of our agendas, but instead of treating them as resistant or non-compliant, the working alliance can be bolstered by treating them as theatrical efforts to show us rather than tell us what’s going on with them. 

File under: The Art of Psychotherapy, Musings and Reflections