New therapists are eager to help, which can be a strength and a deficit. To gauge the mindsets of supervisees or students, I ask, “What do you do in psychotherapy?” A common response is some form of, “People come in with problems. I need to have the solutions to make their problems go away.” It’s as if therapy is perceived as a special forces operation, picking off the bad guys.
It has been my experience that students and new therapists, when asked about their theoretical preference, express wanting to develop a cognitive-behavioral (CBT) skill set. This is likely, at least in part, because it’s what they are primarily exposed to in today’s graduate programs. Further, I’m told, “It gets right to fixing the problem.”
Upon further examination, their expanded definition is sometimes nothing more than identifying symptoms and providing coping skills. Psychotherapy is thus reduced to the fastest possible symptom reduction, as if it were a paint-by-number procedure. While seemingly efficient, there are inherent and fatal flaws in this approach, perhaps most thoroughly examined by Enrico Gnaulati in his, Saving Talk Therapy (1).
Over the years I’ve noticed an increasing assumption that therapy is not, or should not be, an exploratory process. Rather, there is an idea it should be neatly packaged solutions ostensibly remedying problems in short order. This is no doubt further fueled by the uptick in manualized, short-term (8-12 sessions) interventions, implying therapy is supposed to be short.
Despite the implication of these popular tools, psychotherapy is not a race. What’s more, it does not take long in the field to realize that it’s not unusual for any level of meaningful, lasting change to takes six months to a year, regardless of theoretical approach (2).
Sure, therapists wish to relieve patients’ symptoms as soon as possible, but it’s important to realize that ground must be broken to accomplish this. While therapists can offer immediate objective interventions, like diaphragmatic breathing to combat panic, or grounding techniques to interrupt dissociations, it is still necessary to examine the uniqueness of each person’s experience. Do we not need to get to know the person, and allow the person to get to know themselves?
Getting to understand the meaning behind people’s experiences can help unveil the foundational complication for ultimate resolution. This is not a Victorian relic. Modern psychoanalysts and existentialists operate as such, and traditional cognitive-behavioral therapists explore thought processes behind behaviors on the principle that thoughts drive feelings, which drive behaviors.
From its inception, psychotherapy was an activity in exploration and allowing the patient to unfold. By helping a patient explore their being, we help them come to realizations, make painful or shameful confessions, and share intimate details that almost certainly have a bearing on the problematic feelings and symptoms that led to seeking therapy. It is then that the more substantial work may begin of pulling up the anchor of deeply seated dilemmas, and allowing the person to work towards sailing freely once again.
While symptom reduction is relieving, symptoms are just the fruit of a deeper-rooted conflict. I’ve yet to meet, for instance, someone with illness anxiety (hypochondriasis) who simply developed the symptoms, which in turn can simply be given replacement behaviors, and life goes on happily.
While working with patients on reducing their preoccupation with perhaps having a serious illness, I’ve many times discovered they have an unusually pervasive fear of death. This tends to be correlated with a feeling they are not living authentically and fear dying because they have not truly lived. In effect, the hypervigilance for serious illness serves as a check to catch any illness that may prematurely terminate their chance to live authentically. Clearly, helping this type of patient recover from illness anxiety also involves resolving the driving conflict.
Even in this age of increasingly popular, ultra-brief CBT protocols, icons in the CBT field have illustrated that deeper exploration provides a foundation for more substantial work to begin. For example, Jeffrey Young created the “Young Schema Questionnaire” to help such exploration. This is a standardized tool created to help patients with deep-seated maladaptive beliefs explore the troubling way they conceptualize their world and how that leads to their struggle (3). Thus, this insight becomes a springboard for patients to identify and accept what needs changing, and bolsters a collaborative intervention environment.
While people come to therapy for symptom relief, it’s not always as easy as categorical symptom reduction with intensive exposure therapy or teaching them to be responsive and not reactive through a Dialectical Behavioral Therapy (DBT) skills manual. Even DBT, considered a relatively quick and effective approach to borderline personality disorder, involves some deeper exploration for sustained success, and averages six months to one year of treatment.
While successful ultra-brief and single-session therapy does occur, it’s usually a very specific issue with a very motivated person that makes it successful. Most patients are going to need to unfold.
Perhaps the fastest way to psychotherapeutic success is taking the required time, which will vary amongst patients. Before deep work can begin, a therapeutic alliance must be forged, where patients come to trust that the therapist is interested and cares. It is necessary to establish a dynamic where patients may be vulnerable and reveal themselves to expose the conflicts to resolve that will ensure long-term symptom relief.
People in therapy are seeking lasting change. What is the point of quick symptom reduction if the therapist does not work with the person to make sure improvement is sustained, and this newfound way of being has not been woven into the fabric of their lives?
Find Value in Silence
The poet Thomas Carlyle wrote, “Silence is the element in which great things fashion themselves together; that at length they may emerge, full-formed and majestic, into the daylight of Life, which they are thenceforth to rule.” It is no different in psychotherapy, but many therapists squirm in silence, and opportunities for things to emerge can get lost.
When I was new in the field, the most anxiety-provoking encounters in a session were periods of silence. I felt I must have something to say, lest I wasn’t being helpful. Even worse, perhaps it painted me as inept in the eyes of the patient. In time, I learned this was mostly projection, or the assumption others perceived me the way I was viewing myself, as an insecure new therapist.
Today, I’m often reminded of how disquieting silences can be at the outset, as practicum students confess or demonstrate a similar fear. While reviewing student’s practicum videos, palpable discomfort may follow the briefest silence, and there’s a desperate attempt to fill the void. The follow-up supervisory meetings are always rich as the student digests their experience, only to be surprised to discover that filling the void can threaten the therapeutic process.
Once meeting their “silence threshold” a therapist might tell themselves, as an excuse to break the silence, that the patient’s momentary quiet means they no longer want to discuss the topic. Panicked, the therapist offers impulsive commentary or abruptly changes the topic to have something to say. After all, who wants to see a therapist with nothing to offer?
Upon inspection, however, silence is not always indicative of, “It’s your turn to talk.” The patient could be contemplating something the therapist said. Perhaps, while silent, they are mustering the guts, or finding the words for, something that requires attention. Can you think of a time, perhaps in a meeting, when you had something to say but weren’t sure if you should, or how to say it? Now imagine having something critical to share, such as disclosure of abuse, or revealing something one feels ashamed about, and the space that could require to confess or articulate.
With that space in mind, when it seems like the right moment for clients to bring to light an uncomfortable item, any excuse to not have to might be capitalized on. If the therapist becomes talkative during such a pregnant pause, the patient might not try to bring up the topic again, at least not that session, Clearly, providing patients with an ample silence berth is a valuable gesture. With enough silence, they are more likely to crack and use the moment. Like a buried seed, once the shell breaks, new growth begins to emerge.
Indeed, try giving the silence an opportunity to resolve on its own. This will be less of a task with some patients than others, and will become easier as you get to know them.
I frequently sat in silence for up to five minutes with Corrine, a patient I knew well. She would trail off and become contemplative, sometimes spontaneously. At the same time, she began to rhythmically draw her fingertips of one hand down her fingers of the other hand and across her palms in a self-soothing activity. I learned to let Corrine be and focused on watching her hand motions for their hypnotic relaxing effect, which broke any of the silence discomfort I may have experienced as minutes ticked away. More often than not, she would start to reflect on something poignant we touched on immediately prior.
If she did not speak after some time, Corrine would look up and produce a pained smile. This was my cue to coax her. “If I know anything about you,” I’d begin, “when you get quiet and play with your fingers this long, something is brewing inside, and you’re either not sure how to say it or are a little afraid to.” Merely getting her to acknowledge this was usually enough to spur her on. It was as if my reminder of how well we knew each other assured her it was safe to broach any concern.
Being someone ashamed of her body and who generally didn’t think highly of herself, the material sometimes related to intimacy with her boyfriend. Other times, Corrine, afraid to disappoint me, struggled to let me know she had re-engaged in self-destructive activity like drinking benders. Both items were important grist for the therapy mill, which would have been lost if Corrine was not allowed to engage in her process.
When a therapist is just getting to know a patient, it can be helpful to be especially careful not to force away silence. This might occur with an observation like, “What are you thinking about?” It could seem you want to know too much, too fast. It is less confrontational to offer an observation, like, “It’s been my experience that when someone sits quietly in here, there’s something knocking that wants out.” If affirmed, helping the patient partner with their silence can help the state of arrested expression. Posing the paradoxical question, “If that silence was words, what would it be telling me?” has been notably productive over the years.
Other scenarios that can generate patients’ silence as if they are unused to talking about themselves, or are fearful of exposing themselves and appearing weak. This could be related to cultural matters, machismo, or fear of vulnerability. They might answer your questions as briefly as possible, and offer no spontaneous dialogue. Not surprisingly, this terse presentation is a common scenario in males, who are often socialized to feel negatively about help-seeking (4, 5). Autistic people, given the inherent social deficits, can present similarly. It’s important to know your audience, for, in these cases, prolonged silences that were beneficial for others could be very difficult to endure. A therapist would do well to seize these opportunities to teach a patient to interact and communicate.
In situations like this, the patient honestly may not know what to say, awaiting the therapist’s prompts. To promote a forum of focused sharing, the therapist can be productive by blowing on the embers that have begun glowing with simple persuasion, like asking for clarification or other details. Simply being curious and using the most open-ended questioning style is invaluable. “What more can you tell me about that?” “How has that affected you?” or “What’s been helpful to deal with that?” can gain discussion traction.
Showing those prone to this behavior that we’re interested in what they have to say, or gradually exposing them to self-revelation and having them see that it is not disastrous, can work wonders.
Clearly, if someone is not good at sharing themselves, a goal of therapy may have to be improving their ability to be more articulate and willing to share, so we can better understand and address the chief complaint.
Lastly, surely there will be purely oppositional silence, like with rebellious teenagers who see therapy as “stupid,” and they feel they’re forced to be there. No amount of cajoling is likely to make them participate, and it has nothing to do with being an unworthy therapist. Patients like this take significant rapport building, and supervision is often invaluable.
Ask About Meaning
“How does that make you feel?” has its place in the psychotherapist’s arsenal, but it’s not the sharpest tool. If therapists want to cut deeper, asking “What does that mean to you?” or “What’s that like for you?” can engender more robust revelations and therapeutic exchanges.
It’s been my experience that asking about feeling can be a perfunctory activity leading to a dead-end answer. Great, the therapist knows the patient is anxious, depressed or feeling betrayed, but then what? There might be a great leap from “how does that make you feel?” to offering depression or anxiety management skills. Perhaps the therapist attempts to reason with the patient that they have a right to feel betrayed. There is then a comment that the patient doesn’t deserve that, rendering the therapist a cheerleader. Then what?
Although well-meaning, these responses miss a major point of therapy. That is, the necessity to explore the patient’s experience. Whether analytic, cognitive, or person-centered-based approaches, patients must get to know themselves if they are going to change. Thus, feelings are not always the most lucrative query.
Therapists need to be able to mine for, and work with, substantive data for clinical gains. Thankfully, a little curiosity can go a long way. For instance, talking to someone grieving a close relative or friend, their feelings of sorrow and emptiness are often palpable. Asking what the loss means to them, however, can open new therapeutic doors. The emotional turmoil is not only the effect of the deceased’s absence, but the death causes reflections that instigate anxieties about their own mortality or unresolved conflicts.
One patient with this experience offered that since her parents died, it was as if there was nothing between her and the grave now and there is so much more she wanted to do. This revelation made it clear that the loss, though more than a year prior, stirred her own existential angst. Exploration of her life satisfaction and how to achieve goals to feel she had “lived more” followed. Another individual, in therapy after losing a long-term, close friend, lamented that the friend’s absence meant they could never better resolve a conflict that lurked in the shadows. Clinical focus turned towards self-redemption for his role in the conflict.
In another example, Jackson, a 16-year-old teen, while working through his parents’ divorce, discovered his girlfriend cheated on him.
“She said she was only sticking around because she felt bad for me,” lamented Jackson, tearing up.
“What’s it been like for you the past week since it happened?” I asked.
“So angry my head spun. I’m drained. I’ve got no energy to be angry anymore. I want to scream, but I don’t have the energy.”
“Sounds like insult to injury,” I offered. “You were already dealing with so much.” He nodded.
“Jackson,” I continued, “what does all this mean to you?”
“It means I’m on my own. I can’t trust anyone. My parents are too wrapped up in their mess to care about the mess they made for me, and, I guess, I just suck. I give my heart to someone for the first time, and without warning, it doesn’t matter.”
Asking Jackson about the meaning of his experience led him to put words to his internal landscape. This inside-out synopsis provided more than focusing on feelings could provide. His description created an opportunity to examine the maladaptive beliefs that germinated from the problematic experiences, which only served to compound his bad moods. Navigating these beliefs became part of the plan to relieve Jackson of depression.
Therapists working with trauma may also find it a therapy-accelerating question to help understand how trauma affected someone. Therapists can ask about symptoms and provide coping skills and guidance for achieving goals, but wouldn’t it also be helpful to know how a patient is shaped by the meaning they assigned to their experience? Having a patient share that their traumatic experience made them feel “forever broken,” for example, is more fertile ground than an inventory of symptoms to assign coping skills to for a treatment plan.
Asking this “forever broken” patient, “What exactly do you mean by ‘forever broken?’” was crucial to our work. They described an overidentification with the role of victim, perpetuating the other symptoms. Hypervigilance soared, nightmares involved reaching for goals, only to be sabotaged. Understanding this schema helped treatment in that the focus centered on empowerment; cultivating and magnifying other components of her life that negated the role of victim.
Often the juveniles I interview for court are enmeshed in daily marijuana use, binge drinking or vaping nicotine. Problems follow like infractions for marijuana possession in school, perhaps public drunkenness, or getting caught stealing vaping paraphernalia. During the assessments I ask not only about their use history and how it affects them, but what sort of meaning do they assign to the substance use?
I’ve been given answers that it is how they identify with their family, or that they can control how they feel and when. In the cases involving drug dealing, while the money is a motivator, drug culture guarantees excitement in an otherwise dull existence.
In each instance, asking about meaning yielded more potent information than “why” or “how” was likely to. Inquiring about meaning encourages an answer that captures more of the experience. This includes revealing deeper causal factors than self-medication or boredom, or at least factors that encourage the substance use under the circumstances.
Be Attentive to Your Intuition
My colleague, Joseph Shannon, a psychologist specializing in personality, once told me that “listening with the third ear” is a top skill to hone as a therapist. According to author Lee Wallas, the term was first used by the existentialist Friedrich Nietzsche in his 1886 book, Beyond Good and Evil. Given my lack of familiarity with the term I was intrigued, but quickly discovered it’s simply an elaboration of something most people are familiar with: intuition.
While this clinical skill might sound unusual, if you have ever sensed there is more than meets the eye to what the patient is relaying, you’ve experienced it. Clinically, the third ear quietly deciphers indirect communication, helping the therapist read between lines. Just as Spiderman heeds his tingling “Spidey sense” that something is askew and someone needs help, it’s important for clinicians to heed their “Spidey sense.”
Sometimes supervisees confess to encountering situations where it seems their patient is indirectly trying to say something. However, they wonder if it’s too speculative or confrontational to heed the tingling and “go there.” Usually, they fear they may be off the mark, deeming them incompetent and pushing the patient away. Some have justified their defensive unwillingness to consider their intuition by noting, “When the patient is ready, they’ll tell me.”
Or not. Not regarding the intuition could inadvertently prolong misery and unnecessarily perpetuate treatment.
Is it not part of therapist’s duty, part of the therapeutic process, to explore and help patients learn about themselves so they may advance? Is it not poor practice to potentially be encouraging internalization of things that need saying; to not help patients discover and deal with, emerging elephants in the room?
It’s not unusual that patients are on the couch due to some such ineffectual coping strategy as internalization or denial. Thus, the very thing the therapist might be apprehensive of doing is just what they need, and perhaps are even carefully, consciously, asking for. Would you be surprised to learn that sometimes patients (consciously or unconsciously) guide us to make the observation so they don’t have to say it? Something that requires purging may be too painful or embarrassing to mouth, and it’s easier to acknowledge than to explain in order to get it out there. Consider the case of Rob, a successful 34-year-old, who entered therapy for “feeling emptier with age.”
As we explored his life, Rob disclosed an early history of social anxiety that he overcame with therapy. He confessed he was a late bloomer for dating given his teenage angst, but had managed a few, year-long relationships as he emerged from his shell in his 20’s. “As a kid, all I wanted was a nice girlfriend, but I didn’t get that young adult dating experience. The older I get, the harder it is meeting eligible ladies,” Rob lamented. Not about to let it sink him, he accepted singlehood as best he could, travelling abroad and exploring locally on his own.
Rob occasionally traveled with friends, but the ones he had traveled with began having children and were no longer available for adventures. “My friends had to go have kids,” he’d joke, “They don’t know what they’re missing!” Despite this, he regularly spoke of being “Uncle Rob” and beamed when talking about his friends’ toddlers. Other times Rob said, “I do love kids, I just like to give them back. Kids aren’t for me,” noting they’d be hang-ups for his ostensible free spirit.
Soon, my Spidey sense tickled that Rob’s emptiness may well stem from being childless, and I had enough evidence to justify exploration. In a subsequent session, I said, “Rob, we’ve met a few times now, and I’d like to review a bit deeper. Given your history of social anxiety, it’s impressive you’ve become so social and had some successful romantic relationships. It’s got to be disappointing to have progressed exponentially with social comfort, just to encounter the frustration of not securing the relationship you always wanted. While talking about your frustrations with the romantic void, though, you’ve also made some curious comments about kids that I feel deserve exploration. On the one hand, you depict how kids cramp your style. On the other, your happiness is palpable when you bring up kids that are in your life. Correct me if I’m wrong, but I can’t help wondering if there’s an internal conflict regarding kids of your own contributing to that complaint of increasing emptiness.”
Rob eventually confessed, “It’s much easier to say you don’t want kids than to admit you can’t pull it together enough to make it happen.” What followed was an unfolding of Rob’s fear he’d be like his father, plus he feared his own children could be tormented with anxiety as he was. Being in denial allowed him to save face about imperfections. As Rob reflected, he realized that while he enjoyed the women he was with, when talk of longevity and family surfaced, he invariably sabotaged the relationship. He was capable of getting what he wanted, but subconscious security guards only let romance go so far.
Rob isn’t unusual in that patients may be avoiding the truth as ego damage control when they aren’t procuring what they want. As we explored over time, it came to light that the more Rob could not find someone, the more he traveled solo to prove he did not need anyone and to convince himself of his rationalization defense that kids just complicate things. He needed an excuse not only for himself, but as deflection for appearing defective to others.
Imagine if I had not shared what was on my mind about Rob’s material? Clearly, selective hearing for the third ear could have grave consequences to patients. Further, it is important to note that, unlike therapists we might see on the screen, it’s not about trying to shake sense into someone by saying, “Listen to yourself! You’re not finding a relationship because you’re in denial about wanting kids.”
Framed in a disarming way that makes patients see it’s to their benefit, your hunch can be explored and will likely make them interested in examining the idea and weighing its merit. Even if it’s off the mark, that’s not synonymous with therapist incompetence. It demonstrates the need for curiosity about the self, urges willingness to explore, and shows the therapist wants to get to know and understand them, which only strengthens the therapeutic foundation.
***
This content is excerpted and adapted from Smith, A. (2024). Getting Started as a Therapist: 50+ Tips for Clinical Effectiveness. Routledge., with explicit permission from the publisher.
(1) Gnaulati, E. (2018). Saving talk therapy: How health insurers, big pharma, and slanted science are ruining good mental health practice. Beacon Press.
(2) Shedler, J. & Gnaulati, E. (2020, March/April). The tyranny of time. Psychotherapy Networker. https://www.psychotherapynetworker.org/article/tyranny-time
(3) Yalcin, O., Marais. I., Lee C.W., & Correia, H. (2023). The YSQ-R: Predictive validity and comparison to the short and long form Young Schema Questionnaire. International Journal of Environmental Research and Public Health, 20(3).
(4) Cole, B.P., Petronzi, G.J. Singley, D.B., & Baglieri, M. (2018). Predictors of men’s psychotherapy preferences. Counselling and Psychotherapy Research, 19(1), 45-56.
(5) Wendt, D. & Shafer, K., (2016). Gender and attitudes about mental health help seeking: Results from national data. Health & Social Work, 41(1), 20-28.
(6) Wallas, L. (1985). Stories for the third ear: Using hypnotic fables in psychotherapy. Norton.
