Over the course of my 28 years as a therapist, I have told many patients that therapy is like putting puzzle pieces together. It was a metaphor that most of my patients seemed to like and accept.

Like most of us these days, I have extra time due to living with the stay-at-home orders, so I recently purchased a jigsaw puzzle to help manage my anxiety and to enjoy my new-found leisure time. As soon as I began to solve the puzzle, I realized that the metaphor was much more nuanced and complex than I had considered when offering it to my patients. I will elaborate.

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Seeing What’s There

When it was delivered, I first looked at the final product on the box cover. I immediately wanted to solve the puzzle, so eagerly opened the box to see the pieces all jumbled together. I instinctively dumped them scattershot onto the table and turned them all face up.

Therapeutically, this represents the jumble of loss, confusion and pain that brings patients into therapy and the awareness that something needs to change. Although we are careful not to dump all the pieces out at once, it is important to help patients take these jumbled pieces of their lives, turn them face up and begin to sort them out.

With awareness, patients can better their situations, improve their relationships and lead more satisfying lives. For example, for your patients who have found themselves in a series of unsatisfying relationships, the assemblage is asking questions like: “Is it the people out there that are the problem, or is there a common denominator?” “Do your partners possess negative traits?” “Or perhaps do you bring out those qualities in your partners?” If not clarity, then at least direction may begin to emerge at this point in treatment.

Identifying the Borders

Next, I had to find the pieces that made up the edges of the picture.

What are your patients’ edges, and how do the contours of their lives impact them and others? Here, we can use the term coined by Heidegger (which Binswanger introduced into psychology) called Dasein: Each individual’s being-ness in the world. The three types of being-ness are umwelt (interpersonal relationships), mitwelt (engagement with the immediate environment) and eigenwelt (relationship to the self).

The three types of engagement constitute all our thoughts, feelings, attitudes, mental images and more. Where your uncompleted puzzle sits is where their physical, emotional, and psychological boundaries intersect with others, consisting of their connection to the world (welt).

Identify and Group the Colors

I next had to identify the various colors and textures as I grouped them together. I organized the green-yellows into one section and separated the purples, reds, and blues into others.

After the colors and textures had been grouped, continued refinement occurred. I next noticed pieces that composed new colors and textures that I hadn’t seen before. Lighter brown pieces constituted a tree, whereas darker brown ones were the roof of the house.

In therapy, this is the process of identifying your patients’ feelings, thoughts, attitudes and overall behavior, as well as clarifying the expectations, patterns, and challenges in their relationships. In fact, discovering existing and previously unseen colors may be likened to recognizing your patients’ ways of being in their relationships.

There are aspects of their personalities and ways of thinking and feeling that we can help them to identify. How do they treat their spouses within various contexts, such as when they’re stressed out or in a bad mood, and how does their partner’s behavior impact their emotions and self-image? What is the degree of honesty, rivalry and satisfaction with their friends? What is their attitude about their jobs? Conversely, what is the impact of their attitude (sense of safety, optimism, and fulfillment) and self-image (pride, shame, love, or indifference) on others?

Consider the following examples of discovering new colors vis-à-vis interpretations: “I see that you became angry, but I’m wondering if you also felt hurt.” “Is that vulnerability you’re experiencing?” “You felt abandoned when your partner walked out and you followed him from room to room. Was it a response to panic?”

As another example, we might help them learn that they are actually not afraid of conflict when all this time they thought they had been. That’s because conflict exists before the first word is spoken. If a patient’s spouse wants their child to have a play date, but your patient is concerned about her not feeling well and would rather she stay at home, that’s the conflict. What they are actually afraid of are the consequences of bringing up the pre-existing conflict. Do they expect (and receive) anger, the “silent treatment,” or rocking an already rocky boat?

Another example of further clarification and nuance is when patients tell us they’re shy. “Is that always or in certain contexts – parties, public speaking, or on a first date?” This process can help them reduce their blanket “I am” statements and add new facets to their self-image.

Find the Adjacent Issues

As I continued with my puzzle, I recognized which sections were next to one another.

The corollary to therapy is illustrated in the continuing example about conflict. When patients don’t bring up conflict with their partners, they “hold” the conflict 100%. In fact, their partners may not even know there’s a problem.

Therefore, a risk of not acknowledging the conflict is the possible adjacent issue of harboring resentment and living with continuing victimization (which can be very powerful). “I never get what I want.” “I can’t believe how selfish she is.” There is almost always a previously unrecognized issue that lays next to one that they are aware of. The challenge is to recognize what they are and how these adjacent sections fit together.

Tolerate and Accept Emotions

There were times when I felt overwhelmed when doing my jigsaw puzzle: “This is too hard.” I was also hopeful — “I can do this”; frustrated — “Did they include all of the pieces?”; uncertain — “Will I finish it?”; and accomplished — “I did it!”

We are, in a sense, emotional managers for our patients, helping them to self-regulate as they piece together the often difficult experiences of their lives and the underlying feelings. It is important for our patients to tolerate and ultimately accept a wide range of feelings. The goal is not to “get rid of” anxiety, for example, but to reduce its duration, intensity and frequency (the “DIF”) as they increase their emotional tolerance.

Consider Process

What are you and your patients thinking, feeling, and imagining as your patients figuratively put the pieces of their lives together?

The how of therapy is the therapeutic process — everything from the relationship, the way therapy is experienced, what happens within the sessions and the acknowledgment that there are two points of view in the room. The process also incorporates the tribulations, joys, sorrows, frustrations, and hopefulness that we each bring into every encounter. And then there is the possibility that the final product of our therapeutic work may not resemble the image or may vary considerably from their expectation of the goals they brought into treatment. The act of working out their puzzle might have altered the final product.

The Full Picture

While working on my own jigsaw puzzle, I realized that the metaphor of therapy as a jigsaw puzzle is not as simple as I used to suggest to my patients or even realized myself. To help them solve their puzzles, we (and they) must look at the many aspects of their lives; to sort out the jumble into a coherent picture. As we help them through the process of laying out the pieces, finding their edges, sorting and organizing by color and content, they hopefully will learn to look for and at the bigger picture — how they developed certain patterns of behavior, coping strategies and ways of relating to others. They will come to see themselves more clearly and accept themselves more unconditionally, develop and refine facets of their identity and gain insight into who they are. In these ways, effective therapy — like solving a puzzle — is both a demanding and rewarding experience. But unlike the static and store-bought jigsaw that comes in a box, the puzzle of therapy is fluid, and the final product not always available on the box top.

File under: The Art of Psychotherapy, Musings and Reflections