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Case Example Article: Review/Commentary

First, here is the article, for you to read and respond to; my commentary will follow.

 

It’s Never Too Late

By Daniel Siegel

© 2017 Psychotherapy Networker, May/June, pp. 28-29, 49

This article is a transcription of an extemporaneous short story Dr. Siegel delivered over dinner to a Psychotherapy Networker audience during the 2017 annual Networker Symposium Conference.

Daniel Siegel, MD, is a clinical professor of psychiatry at the UCLA School of Medicine, founding co-director of the UCLA Mindful Awareness Research Center, and the executive director of the Mindsight Institute. His latest book is Mind: A Journey to the Heart of Being Human.

 

When I first met Stuart, he was 92 years old. His son, a therapist, had seen me at a conference and decided, for some reason, that I was the guy to treat his normally pugnacious but now depressed father.

As I walked into my waiting room to greet them, Stuart wasted no words. “I don’t know why the hell I’m here,” he said, scowling.

Stuart’s son, Matt, broke in. “My father’s gotten very depressed. He’s withdrawn from interacting with me, my sister, and his grandchildren. He’s even withdrawn from my mom. But I think you can help him.” He turned to Stuart. “Dad, I’ll stay in the waiting room.”

Sitting across from Stuart, I didn’t feel what you often do with someone who’s depressed—a kind of depletion of energy, a sense of despair. Instead, I got a feeling of someone who just didn’t give a crap. Because he had a reputation as one of the most aggressive litigators in the Los Angeles area, I decided to take a low-key stance. “So what do you think is going on?” I asked.

“I think you guys are just idiots,” he said, waving his hand dismissively. “This is all useless.”

“Well, let’s just talk about what’s going on in your life,” I responded.

“Nothing,” he said. But after some prodding he told me that a few months ago, his wife had been hospitalized with pneumonia. When she recovered and came home, he’d become fascinated with the law books he had lying around the house, and was now spending most of his waking hours immersed in them.

“Well, that’s very interesting,” I told him.

“Yeah?” he retorted, leaning forward a bit, ready to spar. “What’s so interesting about that?”

I said, “Just that you’d start studying so much, all of a sudden.” He stared at me. I pressed on: “Would you be willing to answer a few questions? I know it sounds weird, but I’m trained as an attachment researcher, and I do this thing called the Adult Attachment Interview (AAI), where we just kind of talk about your memories of childhood.”

“Look, I’m 92,” he said with disgust. “Why would I care about what happened in my childhood?”

I shrugged casually and responded, “I don’t know—you might just find out something about yourself.”

“Okay. Whatever,” he acquiesced, throwing up his hands. So I went through the AAI with him, and what emerged was a classic portrait of what’s called “dismissing attachment.” The two hallmarks are not remembering much of your childhood and simultaneously insisting that your childhood had no impact whatsoever on your development. Basically, you dismiss the importance of relationships. This became clear when I began to ask Stuart about what he remembered about growing up. “Didn’t I just tell you I’m 92?” he spat.

“I know 92-year-old people who remember a lot about their childhoods,” I told him calmly. “You don’t. And that’s just interesting.”

“What’s so interesting about that?” he snarled.

“Well,” I said, “your wife got pneumonia and then you immerse yourself in studying for hours on end. Your son says you got depressed, but you don’t seem depressed to me.” He made a show of aggrieved patience. I continued, “So it’s interesting that your AAI suggests you might have reacted to early experiences in a way that, to put it simply, shut down half of your brain.”

“To put it simply,” he said immediately, “You’re a moron.” Then something shifted in his expression. “Which half of my brain don’t I have?” he asked. For the first time, there was no trace of contempt.

“I know you have your left half. That’s for sure,” I told him.

He cocked his head slightly and asked, “Which side is that?”

“It’s the side with all the L’s,” I said. “It develops later, it’s logical, it has a kind of linear approach that uses language and deductive reasoning, and it likes making lists—like the one I’m making now. The right brain, on the other hand, is where feelings reside.”

I could almost see the pugnacity drain out of him as he sat with this for a bit. Finally, he said, “There’s this guy, Bill Smith, who started my law firm with me 60 years ago. He’s developed cancer and he’s dying.” He paused. “And I don’t feel anything. My whole life, my whole life, people have said to me, ‘Stuart, how do you feel?’” He shook his head. “I have no idea what they mean by that question.”

At this, I sat back slightly, taking in the vulnerability I sensed beneath his confession. Then he surprised me further with a request. “Can you help me?” he asked, “to feel something?”

“I don’t know why you’d want to change anything, Stuart,” I found myself saying. “You’re 92, after all.”

His forehead wrinkled. “You think it’s too late?”

Sticking with my paradoxical approach, I answered, “Well, I don’t know if it’s too late, but you’ve done so well all this time with half a brain.”

With a sudden sense of urgency, he said, “But maybe before I die, I can find out what the question really means, ‘How do you feel?’”

“Maybe it’s possible we can develop the other hemisphere,” I told him. Aware that Stuart didn’t have all the time in the world, I suggested we meet twice a week.

So we began to do everything you can imagine to activate his right hemisphere. We did nonverbal game-playing, where I asked Stuart to use different tones of voice and facial expressions. We did pantomime. We did exercises to activate autobiographical memory. Since you can’t retrieve a right-hemisphere memory that’s never been encoded, we had to start this very simply. “Tell me what life was like this morning when you woke up,” I’d ask. “Which sock did you put on first? How did you pour your milk on your cereal?” By paying attention to this kind of daily activity, slowly Stuart began to develop his capacity for autobiographical memory. Of course, he thought this was all totally stupid, but he went along with it anyway.

Then one afternoon, Stuart came in and told me that his grandchildren were going skiing and it’s making him feel worried. My heart bumped a little: he used the word feel. “What are you worried about?” I asked.

He thought for a moment and said, “I don’t know. Something about the skiing,” and I flashed on his AAI, when he told me that his brother had been in a skiing accident when they were kids and had lost a leg. When I’d asked Stuart back then how he’d felt about his brother losing a leg, he’d said flatly, “Nothing. He had another one.”

“You told me about your brother losing his leg,” I said to him now. “I’m just wondering if you’re worried about your grandchildren going skiing because you have some leftover feelings about that.”

Tears sprang suddenly to Stuart’s eyes. After a moment, I said, “Do you think you have leftover worries about your brother’s leg?”

“Oh, no. He’s fine,” he said. But once again, he got teary. “I just can’t believe you remember what I say to you,” he added softly after a long pause.

Whoa, I thought. And we just gazed at each other.

At the end of the session, when we shook hands goodbye, Stuart put his other hand on top of our clasped ones and said, “This was amazing.”

In the sessions that followed, I continued to feel like there was now a “we” coming together. Then one morning, about six months into therapy, Stuart’s wife, Helena, called me up. “Dr. Siegel,” she said, “what have you done to my husband? Did you give him a brain transplant?” She was joking but not joking.

“No,” I said. “Why do you ask?”

“Because he’s like a different person,” she answered. She paused a moment. “Some friends moved away the other day and I put my arms on Stuart’s shoulders for a bit of comfort. And he said, ‘That feels good.’ I said, ‘Would you like a shoulder rub?’ And he said, ‘Yes.’” Helena’s voice went thick with emotion. “That’s the only time in 65 years of marriage that he’s let me give him a shoulder massage.”

My first thought was God, why did she wait around for 65 years? But that’s a whole other story.

When Stuart came in next, I told him, “Your wife called.”

“Yeah, yeah, I heard,” he said.

“So what’s the story with the massage?” I asked.

He went silent a moment, then said, “You really wanna know? What we’re doing here, this therapy thing . . .” In a flash, the bellicose litigator reappeared. “First of all, I don’t know why it’s taking so goddamn long. We’ve been working at this for what, six months? I thought it was going to be six weeks. Are you just trying to get my money?”

“Well, I don’t mind your money,” I said. “But no, that’s not why. Therapy usually takes a while. In fact, a lot of people would have to spend six years doing what you’ve done in six months.”

His face softened a bit and he said, “Really? Well, maybe I’m just very motivated because I don’t have that much time left. It’s just a very different feeling to be, uh, alive like this.”

I circled back. “So what’s going on with the massage?”

“You know what happened to my mother?” he responded. I nodded because he’d told me earlier that she’d died when he was young. “It was so painful,” he continued. “And then my father just stopped talking. He didn’t take care of me.” He stared at the rug. “So I decided that I’d never need anyone again. And that’s why, when my wife got pneumonia, I just had to disappear from everyone.”

I stayed quiet, wanting to give him a chance to take in the full impact of what he’d just said. “But with what we’re doing here,” he went on, “I feel I can need people now. I could let Helena massage me. I could let it feel good. And what I want to work on now,” he said, his voice gathering energy, “I want to work on joy. I want to have joy in my life before I go.”

Stuart and I worked together for several more years. He died recently, at the age of 99, having achieved his goal of contacting joy. One of the last times I saw him he told me, “You know, none of this would’ve happened without getting the other half of my brain back.” He looked at me with a kind of wonder, then his eyes crinkled. “And just to set the record straight, you’re not a moron,” he added.

No compliment I’ve ever received has touched me more.

 

Steve’s Commentary

Introduction

I appreciate Daniel’s willingness to present this case description in great detail, which makes it possible to study it, notice what worked and what didn’t, and offer alternative understandings and interventions that might have worked better. Daniel prefers to describe his article as “an extemporaneous short story,” rather than as a “case description in great detail.”

However it is certainly a report of a case, and it is very detailed. Moreover, Marian Sandmaier’s introduction to the stories in the Networker Magazine describes them as follows, “The first-person accounts below, originally composed for a storytelling event at this year’s Networker Symposium.” “Originally composed” seems to contradict the description of Daniel’s story as “extemporaneous” (“spoken or done without preparation.”)

Moreover, the account in the Networker is much too readable and detailed to be a verbatim extemporaneous talk. Either it was written out in detail before delivery (“originally composed”) or heavily edited after delivery (or possibly both) because it’s exceptionally rare for a speaker to talk in such well-formed sentences, with such detailed dialogue.

I want make it as clear as I can that my commentary isn’t about Daniel personally; it’s about his report of his work with this particular client, and a discussion about what I think effective therapy is and isn’t. Though I have never met Daniel personally, I have heard him speak on several occasions, and I know him to be an exceptionally intelligent, hard-working, and good-hearted human being. I feel only good will toward Daniel; my goal is to use his article to illustrate what I think are some very important and practical principles in therapy.

 

Rapport

One of the few things that almost all therapists agree with is that the first task in therapy is to gain rapport with a client. This has been described in a wide variety of ways: “making sure that the client feels understood,” “empathy,” “entering the client’s world,” “establishing a good relationship,” “making a good connection,” “joining with the client,” “acceptance,” and probably several thousand other such phrases.

Stuart begins the session in the waiting room when he says, “I don’t know why the hell I’m here,” he said, scowling. (All quotes from Daniel’s article will be in italics.)

Stuart’s words are a very clear statement that he isn’t interested in therapy, and thinks that it’s a complete waste of time (which he further clarifies with his first sentence after he enters Daniel’s office, “I think you guys are just idiots,” he said, waving his hand dismissively. “This is all useless.”) Stuart is a classic example of an unmotivated client who is dragged into therapy by a concerned family member.

So what does Daniel say to indicate his understanding of Stuart’s experience? “I decided to take a low-key stance. ‘So what do you think is going on?’ I asked.”

Whatever your definition of rapport, understanding, or connecting with a client is, I don’t think that response qualifies. There is no acknowledgement of Stuart’s experience—no joining, no empathy, no entering Stuart’s world, either verbally or non-. Stuart’s attitude is “in-your-face” and “high-key,” Daniel’s response is bland and low-key, almost a scripted caricature of a detached analytic therapist. Stuart’s response clearly indicates zero rapport.

This lack of rapport is particularly curious, since Daniel has written so extensively about rapport in terms of “interpersonal neurobiology,” for instance:

“Our separate bodies become “connected” as energy flows from you in the form of a smile that then connects with me. Your eyes and your ears pick up how that energy was received and two separate “entities” become connected as one in the exchange. This is how people come to feel “close” to each other even with physical distance that separates their physical bodies. Closeness is about resonance where two “systems” become linked as one.”

 

Possible rapport moves

In contrast, I ask you to get a vivid image of Stuart in your mind’s eye, and then observe how this Stuart in your mind responds to the following possible alternate opening responses below:

  1. “Stuart, from what you just said in the waiting room, it’s clear to me that you don’t want to be here, and you think it’s a complete waste of time; do I understand you correctly?” This is an overt straightforward acknowledgement and acceptance that is almost certain to get a “Yes” response from Stuart. This could be followed with a further acknowledgement of his experience by saying, “At your age, you have no time to waste on foolishness,” and/or with a follow-on that could open a door to change, such as, “You may be thinking that your son is a pain in the ass, and he may well be. But I think he loves you and is distressed because you’re AWOL and he wants to connect with you.”
  2. Another possibility would be to say, “Your son brought you here so that I could help you, but I completely get that you don’t think you need any help, and don’t want any. We could just “shoot the shit” for the rest of the hour, but your son is paying for it, and I like to provide value for my pay. If there’s anything in your life that you would like to be different, maybe I could offer some useful input for you to consider. But if everything is totally fine, let’s not waste your time and your son’s money.
  3. Alternately, Daniel could have said, “I’ve known for some time that I’m an idiot, and that what I do is completely useless, but it took me somewhat longer to realize how obvious that is to other people.” Although this response is unexpected, it completely acknowledges Stuart’s experience. However it’s also self-contradictory, because it’s not the kind of thing an idiot would actually say, so it obliquely challenges what Stuart said. Again this could be followed up with an invitation to change.
  4. “You’re a lawyer, and from what I’ve heard, a very skillful one; I know almost nothing about law. Would it make sense for me to tell you how to try a case?” This may seem “off the wall” and irrelevant, but it implies that since Stuart isn’t a therapist, it would be foolish for him to assume that he knows a lot about therapy, and what’s useless and what isn’t.
  5. “Thank you!” (Pause, and wait for a verbal or nonverbal indication that Stuart is puzzled, trying to figure out what he’s being thanked for.) “I really appreciate your being so straight-forward and forthright about your disbelief in therapy. That is so much better than someone who hides their doubts, pussy-foots around, just goes through the motions, and wastes both my time and his. Thank you!” This reframes Stuart’s objection as a doubt, and that his directness will be helpful to the process, rather than a hindrance.
  6. (Based on Daniel’s observation, “Sitting across from Stuart, I didn’t feel what you often do with someone who’s depressed—a kind of depletion of energy, a sense of despair. Instead, I got a feeling of someone who just didn’t give a crap.”) “I agree with you completely!” (Pause, and wait for a verbal or nonverbal indication that Stuart is trying to figure out what is being agreed with.) “I don’t think you’re depressed; I think you just don’t give a crap, and I’d be happy to tell that to your son. However, I also get that your son cares about you, and is genuinely concerned about you. I suggest we ask him to join us so that we can clarify his concerns; what do you think of that possibility?” This response allies with Stuart against his son, at the same time that it allies with the son’s positive intent, and provides an opening for family therapy. As in the previous example, Stuart will be responding instead of being in charge, opening himself to further interventions.
  7. Or, playfully, “You remind me of one of my favorite jokes. In your long career, you have probably heard every lawyer joke a hundred times over, so you must know the answer to this one: ‘What do lawyers use for birth control?’ ” If Stuart answers correctly, “Their personalities,” he said it, not you, and he’s likely to laugh. If he hasn’t heard it, he’s likely to laugh even harder when you tell him the answer. Your response indicates you’re not insulted, and are taking Stuart’s exasperated comment lightly, to be responded to in kind. If someone is pugnacious, few things get their respect faster than to find a worthy opponent. If Stuart is offended, you can say, “You just insulted therapy, so thought I’d return the compliment. You impress me as being the kind of person who can take it as well as dish it out; was I wrong about that?” The word “compliment” is a reframe, even if Stuart rejects it.
  8. Stuart, your son has practically dragged you in here against your will, and you probably wish he’d get off your back and leave you alone. We could invite him to join us, and I’d be happy to try to convince him to do that.” This not only acknowledges Stuart’s experience, it allies with it, and suggests an outcome that Stuart is likely to agree with, which would involve the son in family therapy, providing a richer opportunity to find out what’s going on in more detail.

 

Discussion

Those are only a few possibilities, based on Daniel’s report. If I had a video of their session, there undoubtedly would have been many other communications, both verbal and nonverbal, that could be utilized in similar ways to gain rapport.

Each of these alternatives fully acknowledges Stuart’s experience, and at the same time actively invites the interaction to unfold in a different direction. The core principle is very old and very simple, exemplified by Aikido and the other Asian martial arts. When you are attacked, first actively join with the attack, and then guide it and redirect it in a more useful way, a utilization tactic that was a mainstay in the therapeutic work of Milton Erickson, the most skilled therapist I know of.

There’s no guarantee that Stuart would have responded well to any of these alternatives, but since each one validates and connects with what Stuart has said or done, it’s a lot more likely—and if one doesn’t work, you can always try another. If you imagined Stuart’s response to each of them as I asked you to, I would bet a lot of money that the Stuart in your mind responded in a more positive way than his response to Daniel, “I think you guys are just idiots,” he said, waving his hand dismissively. “This is all useless,” a very explicit and overt indication of a complete lack of rapport.

Daniel’s response to that is to say, “Well, let’s just talk about what’s going on in your life,” another low-key response that sounds like a well-worn “all-purpose” scripted response. This does nothing to acknowledge Stuart’s experience, and Stuart continues to express contempt and disgust for therapy. I think many clients in Stuart’s position would either get up and walk out of the session immediately, or suffer in silence until the end of the hour and never return.

 

Gathering Information

I think it’s almost certain that with even a minimum of rapport, Stuart would have become much more cooperative, and would have opened up much sooner, but since that’s hypothetical, I’ll return to Daniel’s description.

“After some prodding” Daniel learns that Stuart’s wife was in the hospital with pneumonia just before he began to withdraw from his family and become absorbed in his law books. In response to this information, Daniel says, “Well, that’s very interesting,” another bland, non-committal comment that is heavily laden with many possible implications. Stuart predictably responds, “Yeah?” he retorted, leaning forward a bit, ready to spar. “What’s so interesting about that?” Again Daniel’s response is vague and non-committal, “Just that you’d start studying so much, all of a sudden.”

It doesn’t take therapeutic genius to suspect that there may be a causal link between his wife’s illness and Stuart’s subsequent withdrawal. I think it would have been more direct and honest if Daniel had been explicit about what he was thinking, “I wonder if there might be a connection between your wife’s hospitalization and your withdrawing into your law books,” and explore that further. However this kind of interpretation is pretty intellectual and analytical, not likely to be useful unless it’s translated into a sensory-based experience in the present.

I think it would be better for Daniel to keep his guess to himself for the time being, and use the information about his wife’s illness as a new opportunity to gain rapport. “When my wife was in the hospital some years ago, that was very difficult for me, as it is for most people. I wonder what that was like for you?” This both matches and normalizes Stuart’s experience, and is a gentle invitation to discuss it further.

However, instead of following up on his guess, Daniel asks Stuart questions about his childhood memories in the Adult Attachment Interview (AAI). Since Stuart doesn’t see any relevance in childhood memories, this appears to be changing the subject. Predictably, Stuart thinks this is a complete waste of time: “Look, I’m 92,” he said with disgust. “Why would I care about what happened in my childhood?” However, Stuart “acquiesced, throwing up his hands.”

After going through the AAI with Stuart, Daniel says, “I know 92-year-old people who remember a lot about their childhoods,” I told him calmly. “You don’t. And that’s just interesting.” Despite Stuart’s previous antagonistic response to Daniel’s use of the loaded word “interesting,” he uses the word again and Stuart predictably responds, “What’s so interesting about that?” he snarled.

Daniel responds, “Well,” I said, “your wife got pneumonia and then you immerse yourself in studying for hours on end. Your son says you got depressed, but you don’t seem depressed to me.” (This is the first time Daniel acknowledges and agrees with even part of Stuart’s experience.) He made a show of aggrieved patience. I continued, “So it’s interesting that your AAI suggests you might have reacted to early experiences in a way that, to put it simply, shut down half of your brain.”

If I were Stuart, I’d be very annoyed at this third use of the word “interesting,” after twice making it very clear (ready to spar, snarled) that I don’t like it. “This guy isn’t listening to me at all!”

Daniel then describes the antiquated, over-simplified, left-brain, right-brain dichotomy (surprising for someone who is often described as an interpersonal neurobiologist!), closing with, “The right brain, on the other hand, is where feelings reside.” If it was true that Stuart had really “shut down half of his brain,” then Stuart wouldn’t have any feelings at all. However this is clearly false from Daniel’s description of Stuart expressing many different feelings: anger, contempt, disgust, impatience and frustration.

Stuart doesn’t have any difficulty feeling and expressing negative judgmental feelings. His difficulty is much more specific: he only has difficulties with positive feelings of love and connection, and likely also with any feelings of vulnerability. (A lawyer seldom scores any points by being vulnerable.)

However, Daniel’s statement that his childhood experiences “shut down half of your brain” did get Stuart’s attention, and after Daniel explains a bit, concluding with, “The right brain, on the other hand, is where feelings reside,” Stuart’s pugnacity changes to thoughtfulness, and he volunteers that he has no feelings about his friend and partner of 60 years who is dying of cancer. “And I don’t feel anything. My whole life, my whole life, people have said to me, ‘Stuart, how do you feel?’” He shook his head. “I have no idea what they mean by that question,” followed by, “Can you help me?” he asked, “to feel something?”

This is a lovely revelation and a clear statement of a positive outcome that Stuart is committed to. Whatever you think of Daniel’s statement, “The right brain, on the other hand, is where feelings reside,” it got a very useful response from Stuart, both verbally and nonverbally. Then Daniel nicely uses “paradox” (called “reverse psychology” when I was a kid) twice to increase Stuart’s motivation and commitment, and then describes doing a variety of “game-playing” exercises with Stuart to “activate his right hemisphere” with nonverbal pantomime, developing autobiographical memory, etc. Apparently this did work, despite Stuart’s thinking, “this was all totally stupid,” and it’s hard to argue with success. However, none of these very general “right-brain” exercises directly addressed the more specific outcome of eliciting feelings of love and connection. I think it’s likely that Daniel’s sincere good will and companionship may have had a much larger contribution to success than the exercises themselves.

 

Specifying the outcome

I’d like to offer an alternative approach that I think would have been much faster, and more specifically directed at what Stuart wants. First, I’d specify his outcome by pointing out to Stuart that he’s adept at experiencing (and expressing!) negative feelings; what he has difficulty with is experiencing positive feelings of caring and connection. This more specific outcome is much easier to achieve, and it suggests more specific interventions.

Then I might gently ask, “When your wife was in the hospital, did you also have no feelings about that?” If Stuart agrees, that would confirm that we’re on the right track; if he disagrees, we could explore what those feelings were. Either answer moves us closer to the outcome.

When going through the AAI earlier, Daniel learns that Stuart’s brother lost a leg in a skiing accident, and that, “When I’d asked Stuart back then how he’d felt about his brother losing a leg, he’d said flatly, ‘Nothing. He had another one,’ ” which certainly sounds like further confirmation that Stuart needs access to positive feelings of connection.

 

The structure of Stuart’s problem

The key question for therapy is, “How does Stuart manage to have no positive feelings of connection to those he cares for?” The answer to this question isn’t in history (as most therapists assume) the answer is in Stuart’s experience of his history in the present moment. That distinction may seem like petty linguistics, but it invites us to focus on how he experiences memories, rather than the memories themselves. That information ought to tell us what kind of intervention would be most useful in changing his response.

 

Itemizing information

         Distracting When Daniel reports, “When I’d asked Stuart back then how he’d felt about his brother losing a leg, he’d said flatly, ‘Nothing. He had another one,’ ” Stuart is clearly distracting himself from thinking about the lost leg by focusing on the leg that his brother still had. Feeling nothing about the good leg makes perfect sense, but it isn’t an answer to Daniel’s question. It’s likely that Stuart’s recent passion for his law books is distracting him from thinking about his wife’s recent hospitalization, and that he’s also likely distracting himself in a similar way when he thinks about his law partner dying.

         All-or-none thinking Stuart has repeatedly demonstrated that his thinking is typically universal “black or white,” “all-or-none”; “nothing,” “You guys are idiots.” “This is all useless.” “I don’t feel anything.” We also know he’s a lawyer, whose long life has been devoted to skillful verbal arguments that make black-and-white distinctions about guilt and innocence, truth and lying, etc. The opposite of “I don’t feel anything,” is to feel “everything” which Stuart would likely find overwhelming.

         Distancing Stuart is probably also using another common way to avoid feelings, distancing himself from a disturbing memory. Many people think that “distancing” is only metaphoric, but it’s actually very literal in someone’s experience. When an image of a memory is seen at a great distance, (sometimes even miles away) it will be very small, and emotionally inconsequential. There are also other ways to create distancing. For instance seeing a memory as a flat black-and-white photograph framed behind glass will make it appear much less real, and less emotionally evocative. The remedy for distancing is to revivify the memory by bringing it closer until it is experienced life-size, moving, and 3-D, as if it’s happening again in the present moment.

         Abstract thinking The practice of law deals with very abstract concepts like justice, equity, due diligence, fiduciary responsibility, etc., so it’s almost certain that Stuart is adept at that skill. Since “abstract thinking” is itself a poorly understood abstract topic for most people, I’d like to provide you with a direct experience of different levels of abstraction.

Think of someone you have strong feelings about—either positive or negative. . . .

Now imagine that person fairly close to you in a specific context, and notice both what your image of this person looks like, and your feelings toward them. . . .

Now describe that person with a more general word such as “man,” or “woman,” or a word that describes that person’s occupation, such as “accountant” or “bus driver” and notice how that image changes, and how you feel toward that changed image. . . .

Now use an even more general word, such as “mammal,” and notice how the image, and your response to the image changes. . . .

Next use the word “vertebrate” and notice how your image and response changes. . . .

Next use the word “animal,” and notice the changes. . . .

Next use “organism,” and notice the changes. . . .

Finally, notice what image and response you have to a “flow of energy and information,” (a phrase that Daniel often uses). . . .

As you went through this process of going from a very specific and “concrete” image to a much more general and abstract one, I want to point out three things:

  1. Each successive image became less detailed, more fuzzy, vaporous, and indistinct.
  2. The context soon vanished, making it impossible to identify a specific time or place for your experience.
  3. Your feelings became less intense, perhaps dwindling to near zero with “flow of energy and information.”

 

Collating information

If we assume that Stuart is living in a verbal world of distraction, all-or-none abstract thinking, and distancing, all his experience makes complete sense, particularly his lack of feeling (except his contempt for people who don’t think logically the way he does) and his apparent difficulty with autobiographical memory, which requires some context.

Assuming all this is true, it tells us what needs to be done to teach Stuart how to journey from his lofty objective world back to the concrete feeling world of ordinary mortals. We need to focus on a specific time in Stuart’s life when he must have had feelings of connection (but didn’t experience them), elicit a concrete sensory experience of it as if it’s happening in the present moment, and make appropriate changes. This can be done with a past experience, or by eliciting an appropriate experience in the present moment.

 

Intervening in the “past”

When Daniel asks Stuart to respond to the AAI questions, he is assuming that Stuart’s earlier troubling memories are the cause of his inability to feel positive emotions in the present. This is a widespread assumption in therapy, and it’s a reasonable one—even though the evidence for it is almost entirely retrospective rather than prospective. Assuming that is true, one would need to change Stuart’s early memories in order to change his responses in the present. There are a number of ways to change troublesome early memories usefully, some of which are described in detail in an earlier blog post, along with discussion about common mistakes in doing this kind of “inner child” work. However Daniel doesn’t report using any interventions that could change Stuart’s early memories.

 

Intervening in the present

Daniel could have said, “I’m sure that a good lawyer notices when a witness doesn’t answer a question. When I asked you how you felt about your brother losing a leg, you said, ‘He had another one,’ meaning his remaining healthy leg. But I didn’t ask you how you felt about his good leg—or about his arm or his head. I asked you how you felt about his losing the leg that was injured in the skiing accident. That must have been a very serious injury if it required amputation. What do you recall about the extent of his injuries? Did you see him in the hospital before he had the amputation?”

If that didn’t result in Stuart expressing any feelings, it would be easy to take a further step by utilizing what Stuart said in a more explicit experiential test of his not having any feelings. “I want you to close your eyes and imagine that you are sitting at your brother’s bedside in the hospital just before the amputation of his injured leg. As you hear the hospital sounds around you, and notice the antiseptic smell, I want you to look at your brother and say to him, ‘I have no feelings about you losing your leg,’ and just find out what happens next.”

Since that only asks Stuart to say what he has already reported, it’s a request that’s hard to refuse. However, bringing his statement into a specific sensory-rich present context nullifies the distracting, distancing, all-or none abstracting, so it’s a challenge to Stuart’s report that he has no feelings about his brother’s leg amputation that is pretty likely to elicit some kind of feeling.

However unlikely, let’s assume for a moment that Stuart still shows no feeling, either verbally or nonverbally. The same kind of revivification could also be used with his saying that he has no feelings about Bill, his law partner and friend of 60 years who is dying of cancer. “Imagine that Bill is here in the room with us, and you can see the expression on his face as he sits in that chair right there, and tell him, ‘Bill, you’re dying of cancer, and I have no feelings about that,’ and find out what happens when you do that. ”

This same method could also be used with the wife’s hospitalization, “Stuart, I want you to remember the time when your wife was sickest in the hospital and the outcome was most uncertain. See her face as she’s lying in the bed as you tell her, ‘I don’t have any feelings about your being ill,’ and notice what happens next.”

One or more of those scenarios is almost guaranteed to elicit feelings, most likely a combination of feelings of love and connection competing with whatever process has been blocking their expression. That brings both sides of the conflict into focus, and the nature of the blocking will indicate what kind of process will be most useful to resolve it.

The blocking could result from quite a variety of different processes. For instance, if Stuart is angry at his father for abandoning him, the forgiveness process would be useful, but if he feels shame, a different process will be effective. If the events around his mother’s death were traumatic, the phobia method will be most useful, but if feels guilty for his mother’s death, yet another process will be appropriate. When Stuart’s mother’s died when he was young, and his father “stopped talking. He didn’t take care of me,” Stuart concluded, “So I decided that I’d never need anyone again,” what many would call a “belief,” or a “life decision,” that would need to be revised, using yet another process. And of course there may be a combination of these, or other processes, that need to be teased apart and resolved separately.

This approach of revivification and gentle confrontation would directly elicit both the positive feelings, and the processes that block them, without any need to do the much less specific, less effective, and time-consuming “game playing” “right-brain” exercises that Daniel used.

 

Conclusion

Daniel reports convincing evidence, both from Stuart and his wife, that Stuart was happy with the results of his therapy. I generally agree with Daniel’s outcome for Stuart, and success speaks for itself. However Daniel also reports seeing Stuart twice a week for six months, which would total 52 sessions, and seeing him for several more years after that, without specifying how often. So I also agree with Stuart when he says, after six months, I don’t know why it’s taking so goddamn long.” I think that with more rapport, a more specific outcome, and one or more of the interventions briefly outlined in this post, Stuart could have easily reached his outcome much faster, likely in one-tenth of that number of sessions, or possibly even fewer.

 

I sent a draft of this post to Daniel, inviting him to send a response to be added to this post; his office replied as follows:

Thank you for your email inviting Dr. Siegel to respond to your blog. Unfortunately Dr. Siegel is currently unavailable due to his writing deadlines and lecture schedule.”

 

Making Quick Work of Lasting Change

© 2017 Psychotherapy Networker magazine, March/April

Steve Andreas

Imagine that your car is smoking, shaking, and making ugly noises. When you take it to a repair shop, the manager is unusually direct. “We charge $100 an hour, and you’ll have to bring it in weekly so we can develop a working relationship,” he says. “We can’t tell you how long we’ll take to repair it, and we don’t provide estimates or guarantee our work, even for simple repairs like a flat tire or a bad alternator. Since the dropout rate is 20 to 40 percent, overall 30 to 50 percent of cars leave the shop no better than when they came in, and 10 to 20 percent leave in worse shape.”

You’d probably take your car somewhere else for service.

Yet that scenario is a pretty accurate picture of the state of psychotherapy. No wonder that for many suffering people, going to a “shrink” is a desperate and unaffordable last resort. Someone earning minimum wage would have to work a day and a half to pay for an hour of therapy. Not many jobs I can think of pay so well for such mediocre results.

I’ve been a participant-observer of the therapy scene for almost 60 years, and I know that the majority of therapists are sincere, hardworking, and well intentioned. I also recognize that some clients’ difficulties remain intractable to even the most skilled clinicians. The problem, in my view, is that most therapists haven’t been equipped with sufficient perspectives and behavioral-change skills to help people with even the simplest issues.

Moreover, most therapists have no idea how ineffective their work actually is. In a 2012 study of 129 therapists by Steven Walfish and colleagues, published in Psychological Reports, the researchers found that most of their subjects suffered from the “Lake Wobegon effect,” the tendency to overestimate one’s capabilities. More than 90 percent self-rated their psychotherapy skills at the 75th percentile or higher, and all of them rated themselves above the 50th percentile. In fairness, I should note that people in the general population also tend to believe that their intelligence and skills are higher than average. Nonetheless, in his research on therapists, Walfish used a much larger sample size than most such studies do, making the Lake Wobegon effect for clinicians likely to be significant. As I see it, this indicates a lamentable lack of self-awareness and minimum of motivation to improve skills.

It’s widely believed that therapy is generally effective in helping clients over an extended period of months or years. However, the validity of the research often used to back up this view has come under intense scrutiny since Stanford professor John Ioannidis’s article “Why Most Published Research Findings Are False” was published in PLoS Medicine in 2005. He writes, “A research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser pre-selection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance.”

More recently, a team led by Brian Nosek, a social psychologist at the University of Virginia, reviewed research published in 2008 in three major psychological journals, and tried to replicate a hundred of them. The resulting article, published in the August 2015 issue of the journal Science, found that only 36 of 100 replication attempts were successful, with most of those at a lower level of significance than in the original study. Further, William Epstein’s The Illusion of Psychotherapy (1995) scrutinized the research available at that time and identified a blizzard of uncontrolled factors that could account for all the evidence for the effectiveness of psychotherapy. In his 2006 book, Psychotherapy as Religion, Epstein went even further to argue that therapy is an ineffective cultural ritual.

Of course, many therapists freely admit that their years of graduate school didn’t really train them in the skills they need for helping clients in a concrete, expedient way. Most of us spent plenty of time studying theories of therapy, personality, developmental stages, learning, and motivation. But even if we assume those theories are valid, how are we supposed to translate such general knowledge into what to actually say to a client in therapy? We need specific, practical, hands-on training. This means giving therapists a chance to see clinical work in action — the real-time encounters between therapists and clients, the therapists’ interventions and the clients’ responses. Also, rather than reviewing videos of students’ work with clients, most therapy supervision is just discussion of what a student remembers about a session — which is inevitably biased and doesn’t include opportunities for the students’ clients to offer their input.

Study after study has repeatedly shown that the therapist-client relationship is by far the most important indicator of client satisfaction. But the same studies show that the therapist’s theoretical orientation, training, experience, and skill are negligible factors. That suggests to me that what’s called the therapeutic alliance is little more than a popularity contest, in which a successful therapist is perceived to be more caring, accepting, and understanding than anyone else in the client’s life. Since many clients come from difficult backgrounds and the therapist only sees them for an hour or two each week, this is usually not too difficult to achieve.

So here’s what we know so far: the evidence for the effectiveness of psychotherapy is weak; therapy is vastly overpriced for the uncertain results it produces; and therapy education rarely teaches us how to actually work with clients and improve what we do, especially since few therapists release videos of their in-the-moment work with clients. In my view, at best, much of psychotherapy is a pseudoscience, promising far more than it can deliver. At worst, it’s a group of psychotheologies competing for market share, with buzzwords like mindfulness, self-compassion, and neuroscience.

Discouraged? Nettled? Exasperated? Bear with me. There’s good news, too.

 

The Dance of the Nonverbal

What if there were a few basic principles and methods that make therapeutic change far simpler and easier — and much more enjoyable for both client and therapist — than most people think is possible? And what if we could often bring about that change in a very short time by modifying a few unconscious processes? Not only is this possible, but there’s already a coherent body of knowledge and practice to guide us in eliciting change in the moment, confirmed by longer-term follow-up in the real world.

I’ve deliberately refrained from naming this approach to keep it from being dismissed as yet another of the thousand or so named models out there, most of which are only different rebrandings of existing therapies with slight variations. If we must have a name for this way of working with internal processes, let’s call it essentials of therapeutic change. It’s a rich tapestry woven from many different threads, from cognitive linguistics to clinical hypnosis, developed by studying the work of therapeutic greats such as Milton Erickson, Virgina Satir, and Fritz Perls, as well as the work of a few outstanding researchers, like Daniel Kahneman’s two systems of thinking and Thomas Gilovich’s work on regret. Developed largely outside of mainstream academia, many different practitioners have been involved in its growth over at least four decades. Few of us could be called originators; most are fieldworkers or adapters.

Much of the development has come from eliciting overlooked, often unconscious, aspects of the before-and-after experience of clients who have recovered from a problem. For instance, people who were no longer depressed had internal images of the future that were large, bright, and colorful; but when they were depressed, their images were small, dim, and colorless. This suggested that helping a depressed client adjust his or her unconscious images of the future to be larger, brighter, and more colorful could be useful. It sounds far too simple to be true, but the videos and feedback from clients speak with authority.

Of course, some complex issues are still difficult to treat with this approach, but many common ones that clients bring to therapy — anxiety, phobias, grief, shame, guilt, self-judgment, critical internal voices, unwanted habits, and general overwhelm — can be dependably resolved with established procedures, usually in the course of a single session. Many readers will understandably doubt this claim, especially in light of my arguments above about therapy’s generally mediocre results. So my hope is to demonstrate how it works with a case study of resolving lifelong anxiety, backed up by short, unedited YouTube videos of complete sessions and three years of follow-up.

Watching the client’s nonverbal responses in the videos will be essential to an understanding of how different this approach is from most therapy. Learning how to do it doesn’t require studying a complex theoretical orientation. But it does involve paying close attention to the mostly unconscious, nonverbal process details of your clients’ experience of their problems, and learning how to ask questions that elicit additional process elements.

To make this approach as user-friendly as possible, here are seven practical principles for making sense out of the case study that follows. You can easily test and confirm each of these principles in your own experience, or in your work with clients.

  1. Many problems that bring clients to therapy are caused by unconscious processes over which they have no conscious control. By unconscious I don’t mean Freud’s seething cauldron of inhibited desires: I simply mean aspects of our internal experience that we don’t usually notice, like the size, closeness, and color of a troubling memory image, or the tempo, tonality, and volume of a critical internal voice. If our problems were the result of conscious processes, we could just stop doing them, as satirized in Bob Newhart’s short YouTube video in which the therapist listens to the client’s problem and then responds with his universal solution: a loud, emphatic “Stop it!” But since most problems are caused by unconscious processes, that’s where we need to direct our interventions.

For instance, a client might say, “That screw-up I made is right in my face,” while gesturing with his palm close in front of his face as his head recoils slightly. If you imagine having that experience yourself, you can notice that if that image of the screwup were smaller and farther away, or off to the side or behind you, the content of the image would be easier to deal with. It takes only minutes to ask clients to try these kinds of process changes, and to find out the extent to which they’re useful in changing their problematic response. I often tell clients, “I’m the authority on what might work; you’re the authority on what does.”

  1. Change the cause, not the symptom. Returning to the metaphor of a malfunctioning car, if your car is smoking, shaking, and making ugly noises, those are important signals of a problem. They may give you some indication about what the problem is, but they’re never what needs to be changed. Filtering the exhaust, using vibration dampers, or soundproofing won’t solve the problem in the car’s engine.

In the same way, unpleasant feelings are important signals that something is wrong, but they’re only symptoms of an unconscious cause. For instance, feeling depressed is often a signal that someone has an internal image of a bleak future. Or perhaps there’s a low, slow, internal voice saying, “It’s hopeless.” To change the feeling, he or she has to change the image or voice that elicits the feeling.

  1. Discover the unconscious processes that elicit feelings. These processes are mostly outside of our awareness, but they can become conscious if we pay attention to them. The client’s gestures, direction of gaze, and other nonverbal behaviors often reveal important aspects of their internal experiences. For example, if a client talks about a troubling memory while gesturing in front of her with hands two feet apart, this tells you where her memory image is, and how large it is. Once we’re aware of the process, we can try simple interventions. If the therapist reaches out in the same spatial location and says, “Tell me about that memory again” while moving his hands somewhat closer together and farther away from where the client gestured, that’s an unconscious invitation to see the memory as a smaller image, at a greater distance, which usually makes it less emotionally disturbing, and thus easier to address and learn from. Most of these processes are nonverbal — the sensory parameters of an image or inner voice, in contrast to the content — and eliciting them is often as simple as asking questions like, “Where is that disturbing image? How large is it? Is it in color or black and white? Is it moving or still? Is it 3-D or flat?”
  2. Adjust, don’t eliminate. Many approaches try to abolish a troublesome process by eliciting a competing response, such as teaching an anxious client to think of a soothing context, slow his breathing, or relax her muscles. It’s much easier and more effective to make small changes in the troublesome process itself. For instance, if you hear an internal voice saying, “We’re going to crash!” in a fast, high-pitched voice, you’re likely to feel anxious. Disputing the content of what the voice says will have little or no effect. However, if you hear the same anxiety-producing words — “We’re going to crash” — spoken in a slow, low, bored tone, with a hint of a yawn, you’re likely to experience full-body relaxation without any conscious effort. The process is almost always more important than the content. For example, a sarcastic tonality can completely reverse the meaning of any set of words.

Another example: someone who’s overwhelmed is typically trying to cope with too many images at once — often big, close, colorful, moving images with sound, like a movie. If you invite him to allow all those images to retreat into the background, dimming the color, muting the sound, and perhaps pausing the movie as a still, the sense of being overwhelmed is likely to diminish, or even disappear. Then you can suggest that he scan the still images and decide which one is most urgent to address. Ask him to bring that one into the foreground again. Then turn it back into a movie so he can see it in clear detail, process the content, and decide what to do about it, before doing the same with the next most important image.

  1. The importance of gesture and language. Since a major part of your communication with a client is nonverbal, it’s important to make sure that your gestures congruently specify and support the change you ask a client to make. If you say, “Move the image of that critical colleague in front of your face around to a location behind you,” many clients will be able to do that easily; they’d just never thought of doing it before. However, if you first gesture to where their image is, and then pantomime grasping it and moving it behind yourself with your hand, that will make it even easier for clients to succeed in following your instructions. Doing this is also a clear nonverbal message that you’re taking on their experience as if it were your own, signaling respect and empathy in a way that’s far more subtle and impactful than the formulaic verbal, “I understand.” As you gesture, you can even say, “Allow that distressing image to move around behind you,” which hypnotically presupposes that it will move.

If the image won’t move, you can use a hypothetical “as if” frame while gesturing appropriately: “If that image were to move around behind you, how would that change your response to it?” If the image moves but then returns to its original location, you can say, “Imagine that you put some Velcro on the back, so you can hear that soft sound Velcro makes as you push it down in place back there,” while gesturing to the new location.

One client experiencing significant feelings of being overwhelmed was confused because she couldn’t put her internal images of moving her family and possessions from one coast to the other into an orderly sequence. The images of the tasks involved in the move — many of which depended on first doing others — wouldn’t stay put; they wobbled, slipped, drifted around, and moved in and out chaotically. When I suggested putting Velcro on the back of each image, she could put her images into a sequence that stayed still, allowing her to examine the sequence, notice what was out of place, and move images until the sequence made sense and was less overwhelming.

  1. Our internal world is a representation of our external world. If a threat comes closer in the external world — let’s say you’re visiting Yellowstone and a bison approaches you at a good clip — you’ll react more fearfully than if you see it from a distance. The same is true in our internal world: when a threatening image moves closer and becomes larger, it evokes stronger feelings, and vice-versa. Imagine a snarling pit bull coming rapidly toward you. Now imagine the same dog, still snarling but backing up and moving away from you, and notice how your feelings are different. Knowing that the internal world is similar to the external lets us predict how a given internal change might help a client become less reactive. Asking a client to “put a frame around that image,” for example, will typically result in seeing the internal image as flat, rather than 3-D, since most framed images we’ve seen are flat. A flat image appears less real and is therefore less likely to elicit a strong emotional response.
  2. Point of view is a key process element. Any memory (as well as any image of the future) can be experienced either as being inside it (reliving it) or being outside it (seeing it as a detached observer). For instance, imagine sitting in the first car on a roller coaster just as it begins its first big descent. As you feel a breeze ruffling your hair, you can see your hands gripping the safety bar in front of you as you look down at the ant-sized people far below. Now imagine sitting on a park bench, looking up, and seeing yourself far away in the roller coaster. This is a choice in point of view that everyone has, but most people don’t realize they have this choice until it’s suggested to them.

When a client remembers a terrifying memory by being inside it, that experience elicits what’s called a phobia or a PTSD flashback. If he steps outside that experience and views the same event as an objective observer in a movie theater, his terror response will diminish. (A complete nine-minute video of this process, along with a 25-year videotaped follow-up with the client is available.)

Sometimes, however, we need to tell a client to reverse this process and move from an “outside” viewpoint to an “inside” one. For example, if a grieving client remembers her dead lover from an outside point of view, the feelings of affection and closeness that she shared with the lover will be absent, leaving only a horrible feeling of emptiness. To resolve her grief, she needs to step back inside the memory to regain the special feelings of love, warmth, and connection.

These examples highlight yet another important principle: every mental process can be useful or not useful, depending on the larger context and the client’s desired outcome. A big, bright, “inside” image of a party can motivate us to achieve a useful goal, such as being with friends. The same image, however, can lure us into harmful behaviors, such as taking drugs or drinking too much alcohol.

 

Resolving Lifelong Anxiety

As we all know, anxiety is one of the most common problems our clients present. Most currently used treatments — such as learning relaxation and breathing skills, medication, and exposure — are directed toward the symptoms, rather than the cause, and are typically only partially successful.

First, let’s look at anxiety in its larger context. Planning is our ability to forecast events and prepare a response to them. When we foresee an unpleasant event, we experience anxiety. (It’s important to note that this is structurally different from a phobic fear response elicited by past traumatic memories.) When planning reaches a satisfactory conclusion, anxiety stops. But when we can’t reach a satisfactory conclusion, we continue to search for a solution indefinitely. In short, we worry. When we worry about a future that appears unavoidably dangerous or unpleasant, we continue to anxiously search for a better outcome.

Sometimes anxiety is useful, because it warns us about an unpleasant experience that we can do something about. For example, if you’re worried about being in an airplane crash and your anxiety keeps you from buying a plane ticket, then it’s effective in avoiding that possibility. But once you’ve decided to fly, and have put your safety in the hands of people and machines over which you have no control, anxiety is no longer useful.

Quite often anxiety is only a habitual, learned response to a perceived challenge, even when you’re well prepared for it. That was the case for Joan, who’d suffered, in her words, from “lifelong anxiety.” What follows is a condensed description of my work with her. (To observe exactly what occurred, see the complete, unedited 14-minute YouTube video)

Anxiety didn’t prevent Joan from doing things; it just made her miserable. An accomplished professional in her mid-60’s, she had a PhD in business and had held several high-level positions in successful companies. Now she was in full-time private practice as a hypnotherapist specializing in treating PTSD. Petite and smartly dressed, with short graying hair and an impish smile, Joan told me she experienced strong anxiety whenever she was facing a challenge, particularly when she was alone and potentially helpless. A recent example: she’d driven alone more than 700 miles across the desert from Arizona to Colorado to participate in my workshop, and had been anxious during the whole trip. So when I asked for a volunteer to demonstrate a method for resolving anxiety, Joan had hesitated briefly and then raised her hand.

When I asked her to imagine being in a situation where she got anxious and to tell me about the experience, she reported hearing a fast, high-pitched, internal voice yelling, “I can’t do this!” over and over, followed by a flood of anxious feelings.

“Notice where the feeling of anxiety starts, and where it goes to,” I said. After some searching, she reported that it started as a feeling of tightness in the back of her neck, then came around her right shoulder, traveled down the right side of her body and into her groin. “As the feeling moves along this path, tell me a little bit about the size of the path,” I continued. “Does it start out small and get larger as it goes down, or is it all the same size?”

Joan replied, “It’s big, immense,” gesturing broadly with outstretched arms. Although it may seem strange that someone could feel a feeling that’s partly outside the body, that’s what many people report. When I asked what color it was, she told me it was white.

“This last question may seem a little bit weird,” I said. “As it goes from your neck down your body, which way does it spin?” Joan quickly gestured with her right hand.

At this point, we were finished with information-gathering and ready for the intervention. “Joan,” I said, “I want you to imagine yourself in one of these situations that’s made you anxious — like driving across the desert to get here — and feel it start in your neck and move down your body. But this time I want you to reverse the direction of spin, change the color from white to one you like better, and add some sparkles to it. Just do that, and find out what happens.”

After a few moments, Joan said, “It feels better. It feels a lot better.” She looked mystified. “It’s really nice. This whole side of my body is relaxing. I’m breathing better.” The change was instantaneous, and her verbal report was congruently confirmed nonverbally. “Would it be OK for you to have this response instead of the old one?” I asked. She immediately responded, “Oh, yes!”

“If you put yourself in the situation that used to make you anxious, what’s it like now?” I asked. Shrugging, Joan said, “It’s easy.” Her new response was qualitatively different, not just a reduction of intensity in her old anxious response. But would it last?

“Some people need a little bit more practice, and that’s what I’m checking for,” I told her, pointing out that if her new response wasn’t automatic in the future, she now had something that she could do on the spot, on her own, to ease the anxiety. Then I asked her to test her new response repeatedly in her imagination. “Think about other situations that you used to get anxious in, and see if you can get the old response back,” I suggested. I did this for three related reasons: to make sure that she had no objection to the new response, to be sure the new response was dependably automatic, and to see that it had generalized to all the different situations in which she used to be anxious.

As Joan imagined several of these, she mused to herself, “One would be in the future, looking at finances, and that’s fine now.” She paused, imagining another situation. “Driving back home, fine. If I get in a place where there’s no cell reception, well, there I am, and I’ll deal with it then.” At the end of the session she said, “What a wonderful gift!”

 

Transforming Negative Self-Talk

To further reduce the possibility that Joan might revert to her old response, I set out to help her change the anxious voice that repeatedly yelled, “I can’t do it!” If that voice remained loud, tense, high-pitched, and fast in tempo, it could re-elicit the cascade of anxious feelings. So I used a method I learned from Melanie Davis, a therapist in the UK, in which the tonality of a troublesome internal voice is changed and the sentence is re-punctuated into two or more separate messages. On the next day of the training, I wrote Joan’s internal sentence — I can’t do it — on a flip chart. Seeing the words on the chart is already an intervention, because it puts some distance between Joan and the words, externalizing them and making it easier for her to observe them dispassionately. More importantly, I knew that the written words, without italics or an exclamation point, were likely to omit or soften the tonal aspects (panicked yelling) of her self-talk. So when Joan reads the words on the flip chart, she’ll be able to hear it in the neutral tone of voice that she typically uses when reading.

I started with a useful reframe that I knew Joan already agreed with because of her previous training — that every part of her, even her anxiety, has positive intent. If she didn’t already have this understanding, I’d have elicited specific times in her life when her positive intent had resulted in behavior that had been less than useful, like yelling harshly at a child with the intent of keeping him or her safe.

Next I said, “Now let me show you something. Can’t is really can not, right?” (Separating can’t into can and not has the effect of shifting the meaning from inability to possibility and choice: she can always choose to not do it.) So I rewrote her sentence this way on the flip chart: I can – not – do it.

This new punctuation divided her sentence into three separate messages. Joan gazed at the words, looked a bit surprised, and then said softly, “Oh, wow. The whole world opened up.” She gestured with both arms in a soft expansive movement. Although she was aware of the sudden, qualitative change in her feelings — from helplessness to freedom and possibility — she had no idea how that occurred, even after I asked her repeatedly, and even though she was in a training that focused on tracking the elements of this kind of rapid change.

I went on to offer her further modifications of the tonal aspects of the three separate messages: saying “I can” in a confident tone, shifting “not” into a rhetorical question (“not?”), and using a command tone for “do it!” This further amplified the change she’d already made, and Joan responded, “Oh, I like that.” (You can watch this unedited four-minute session on YouTube).

The following morning, Joan reported to the group that her car had failed to start and that she’d calmly phoned for help, whereas previously she’d have felt helpless and panicky. After the training, she drove home alone across the desert, feeling centered and secure the whole way. Three years later, Joan reports that these changes remain in place. She’s been able to remain calm in finding solutions to a variety of significant life challenges, including dealing with her mother’s failing health. She recently wrote to me, “I’ve used this process successfully with my clients and friends. I even got a full night’s sleep before making a recent presentation. Prior to the work we did, my anxiety would’ve been way too high for that.”

 

                           *       *       *       *       *

 

This way of working with the largely unconscious structure of present experience — in contrast to working with the history that created that structure — makes therapeutic change much more like reprogramming a computer: just find out what isn’t working in the client’s experiential software and offer simple interventions to alter the process. This simplicity has made it easy for many to dismiss the resulting changes as superficial quick fixes, presupposing that they don’t address “deep” issues and won’t last. Though clients are often initially skeptical of this approach — and real-world results are the only way to test it dependably — I’ve never yet had a client complain, “That was just too fast. Couldn’t you have taken longer?”

As I mentioned earlier, some clinical issues are still difficult to resolve quickly with this approach, though the list gets shorter each year. For instance, complex PTSD is a tangled mixture of terrifying flashbacks, guilt, shame, regret, anxiety, disappointment, and depression, often compounded by years of self-medication with drugs and the consequences of poor decisions resulting from that. It’s hard to disentangle and address all those different aspects, even when there are dependable processes for each of them individually.

Other problems are intractable because the client has no motivation to resolve them. For instance, narcissism feels good and is often richly rewarded in business and politics. The structure of narcissism is fairly simple, and I’ve been successful in changing it when it hasn’t gone too far; after all, each of us has at least some of narcissistic qualities. But I have no idea how to convince a full-blown narcissist that such a change would be useful. Paranoia has a simple structure, and is also easy to change if it hasn’t gone too far. But again, I have no idea how to enter the tight and vigilant world of a full-blown paranoid person in order to convince that person of the value of changing.

Keeping these and other limitations in mind can be useful in maintaining a sense of balance and perspective. But they don’t overshadow the immense pleasure and importance of being able to resolve many simple client problems rapidly, making therapy much cheaper, effective, and more available to so many who need it.

Working with a shame-inducing internal voice

I got a lovely email recently from a therapist reporting on a session:

 

I did a client session in November 2016 regarding old and new traumas with a 30-year-old woman who was sexually assaulted when she was 18. She had cancelled and rescheduled several times, but she finally found a time she could come without her two small children.

We were discussing the phobia process and when I asked if she had any questions, she was tearful, voice shaking, and she shared a strong disturbing thought, “You are going to take this from me.” She had a strong belief that she “should” feel the reactions to the memories of the assault (hypervigilance, somatic symptoms when memories arose, discomfort with physical contact with her partner).

We had planned to use the movie theater/rewind method to address the phobic response to her traumatic memories, but instead we addressed this negative internal voice that thought she “should” have this reaction. We shifted to the Troublesome Internal Voice Transformation method from the online PTSD training. She quickly identified the negative voice as being that of the boyfriend she had at the time (not the person who assaulted her), who shamed and manipulated her when he found out about the assault. She had a very profound experience when she realized this — her affect changed dramatically, she was quiet and smiling and relaxed, so there was no need to do the phobia process.

She said she hadn’t realized that the voice was “not me,” and when she had this realization, she felt free to stop listening to it. We’ve met twice since that session, most recently in early March, and the results have held. Below is the email I got from her the next morning after our session.

—Susan Malcolm LCSW, Portland Maine

 

“I literally cannot explain it. I am happy. I could not fall asleep last night because I am happy. I feel like I am that girl that was lost 12 years ago that was once so happy and liked herself. I am a little in shock from it still, but to have this box that was gross and oozing yesterday be beautiful and dressed up today is just amazing. All my anxiety that I have been having about everything is gone. I want to spend time with my kids, I want to talk to my husband about all the weird crazy things in my mind, and I don’t even care about talking about building a house anymore. (Yes, it’s still overwhelming, but I am not scared about it anymore.) It is literally unexplainable and amazing all at once. I cannot say thank you enough. I want this to be available for everyone. This is the craziest thing that everyone with PTSD should go through. E.V.E.R.Y.O.N.E.”

 

Comments by Steve Andreas

Susan’s lovely example is a reminder that when someone says they have a phobia, or PTSD, or anything else, those words may not accurately indicate the structure of what is troubling them. Many people use the words “trauma” and “PTSD” for a very wide range of different troubling experiences. If Susan had gone ahead with the phobia cure, either it wouldn’t have worked at all, or it might have worked with her memory of the assault itself. But it wouldn’t have resolved her crippling shame induced by the voice of her old boyfriend. It’s only too bad that she had to suffer needlessly for 12 years from something was so easily resolved in a single session. When Susan asked her if she recognized the voice, the realization that the troubling voice wasn’t hers probably only took a few seconds — a sweet example of what I call “Briefest Therapy.”

Small-Scope Synesthesia

In response to my previous blog post on synesthesia, Gary Skaleski (MA, LPC, currently working as an EAP case manager) wrote the following:

 

“About 1976-77 John Grinder was teaching about modalities, and at one point came up with a technique which I had not heard anyone else talk about, not written up as far as I know, but which I found helpful. We started talking about synesthesia, and while discussing overlap, John suggested we spend time every day mapping from one modality to another, but at such a small level that we would never get overwhelmed.  Example: take a sound.  Not a word (big scope: “Amen”) but part of that word (‘Ah’) and turn that into a feeling (not emotion, but how and where that sound feels physically in or on your body), then take that feeling and turn it into a visual image (again, not a scene but a simple shape, color, etc.).

“The order is not important, and could start with a feeling, to visual to auditory, etc.  Just keep overlapping at this small level.  After a few weeks of doing this, I noticed a significant drop in my general anxiety — things that might have ‘gotten under my skin’ did not elicit as large a response as before.

“It’s an interesting and effective technique, and in this age of mindfulness and meditation, it’s also a way someone could take any experience, chunk it down, and use the small elements of that experience to remap at an equivalent level in all systems, so going back to thinking about the original experience is not as overwhelming as before.”

 

I wrote back: “Gary, thanks for your note. I remember Grinder presenting this ‘small chunk overlap’ as a way to work with schizophrenia about 1978 (and it may be mentioned in Frogs into Princes) as a gentle and non-threatening way to integrate modalities. I don’t know anyone (other than you) who has tried it, but it certainly sounds right, and I can’t see how it could possibly hurt. Boredom would probably keep me from spending enough time doing it to be worthwhile, but others might not be so encumbered.

 

Gary replied: “This was early NLP, so submodalities and spinning feelings were still in the distant future.  I would probably spend about 20-30 minutes a day doing this, and it was fascinating to concentrate on the smallest detail (a line, different parts of words with different sounds, pitches, volume, and feelings here and there (equivalent to the est technique of asking, ‘What color is your headache?  Where is it located?  What shape is it,’ asking this over and over until it changed or disappeared).  Anyway, we were still green in those days and John could have told me to put my head in a garbage can and yell to cure something and I probably would have done it.”

 

Steve wrote to John Grinder, asking him to look over the above to see if it accurately represented his memory and understanding, and/or suggest changes or additions; his reply is below:

 

John Grinder replied: “Your account strikes me as entirely plausible. I have no idea about the dates involved — it sounds close to when the period when we were exploring synesthesia. I have had good success in cases of clients who get triggered by X; if you elicit a reasonably well-specified description of the triggering stimuli, you can decompose them into their submodality components, and use small pieces of those components mapped onto other submodalities of other representational systems through synesthesia circuitry (e.g. swatches of color, small sounds, any of the submodalities kinesthetically) and either have the client’s unconscious (ideally) or in some cases, have the client deliberately present to him/herself these small chunk elements (and therefore meaningless and ineffective as a trigger), the triggers lose their ability to access the states that they have been historically associated with. In my experience, this has worked with the full range of clients, from chronic schizophrenics to off-the-street clients.

“I have used the small chunk approach with synesthesia mapping with many clients over the years — it works very well (for me, at least) with things like pain control. I remember taking a fall climbing and breaking a bone in my ankle. I had about one and a half miles to get back to my pickup truck. Because of my fascination with, and playing around with, such synesthesia mapping, I mapped the pain (important to maintain a sensing of the pain to avoid doing things that would exacerbate the injury) onto pressure and heat. By so doing, it was able to carefully return to my truck without further damaging my ankle.

“I have used it with women who want to be fully conscious during childbirth but not feel the pain. One striking example was a woman who has strong K > V circuitry. I had her practice for some weeks during her pregnancy. When she went into labor, the professional medical types wired her for contractions as well as the baby for heartbeat, breathing. She was walking around the room talking to her mom and friends, and the nurses were looking worried and constantly checking the instruments. Fortunately they were intelligent enough not to mention that according to the instruments, the woman should be in severe pain. The baby was born premature and was kept in a critical care unit because the brainstem breathing was not mature enough to safely maintain the breathing patterns. The mother decided to stay in the hospital to be close to her baby. Two or three days after the birth, she, the head nurse, and her mother walked in the room where she had been in labor. She stepped through the door, stopped abruptly and exclaimed, ‘They have painted the room!’ What had happened was that practicing the synesthesia patterning (K >V) kicked in unconsciously, and she had succeeded in remaining conscious and mobile by changing the colors in the room to one that served as a measurement of the pain without the requirement of experiencing the pain.

“I was amused by Gary’s statement about yelling into a garbage can — it is certainly accurate that congruency on the part of the agent of change is a powerful aspect of doing change work.”

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What is Synesthesia?

One problem that crops up repeatedly in NLP is imprecision in the meaning of a word, creating an ambiguity about what kind of sensory experience a word refers to. Since most NLP works directly with changing sensory experience, it’s crucial to know what that is. The word “synesthesia” has been used in NLP for two very different kinds of experience, and this often causes confusion — whether or not that confusion is noticed. Below is an online definition of what the wider world means by the word synesthesia:

Synesthesia is a condition in which one sense (for example, hearing) is simultaneously perceived as if by one or more additional senses such as sight. Another form of synesthesia joins objects such as letters, shapes, numbers or people’s names with a sensory perception such as smell, color or flavor. The word synesthesia comes from two Greek words, syn (together) and aisthesis (perception). Therefore, synesthesia literally means ‘joined perception.’ ”

I want to point out three crucial criteria embedded in this quote: two (or more) sensory perceptions are joined simultaneously, in the same location in space and time. When someone sees a number in a particular color, they see a colored number — they don’t see a number adjacent to a swatch of color, or a number followed by a color, or a color followed by a number.

Synesthesia is often described as something rare and unusual, and it’s true that seeing letters or numbers in color is uncommon. Years ago when Connirae and I were investigating different spelling strategies in great detail, we found one woman who saw each letter of the alphabet in a specific individual color. When she spelled a word, she knew it was correct if all the letters changed to one color! Although this was a complex way of spelling words, and I wouldn’t recommend it over the “good spelling strategy” discovered in the early days of NLP, it did work for her.

Another aspect of synesthesia is that while it may seem unusual to those who don’t experience it, I have never heard of it being a problem for those who do. It is fairly common among “autistic savants” but it isn’t a cause of their limitations. Rather it is always a useful part of some amazing skills that are far beyond what most of us can do, such as quickly noticing if a large number is prime or not, or multiplying two large numbers. I have never heard of anyone for whom a synesthesia was a significant problem; rather it is an interesting embellishment of experience, and it is often credited with contributing to creativity. Here is a short TED talk by a synesthete; search online for “synesthesia savant” for other descriptions.

Actually we all experience synesthesia in ways that are so commonplace that it’s easy to overlook, and not realize that it is fundamentally the same process. As I type these words, the feeling in my fingers occurs at the same time — and in the same location — as the sight of my fingers moving on the keys, and the clicking sound of the keys. The same is true if I close my eyes and imagine typing — I see and feel my fingers moving on the keys, and hear the clicking sound that the keys make.

This is only an example of how our brains integrate the information coming from the different senses into a single coherent experience.

Imagine how weird and disconcerting it would be if those three different perceptions occurred in different locations and at different times! The feedback information from each sense would be out of synchrony with the others, making it difficult to learn even the simplest of motions, like bringing a glass to my lips to take a drink.

 

Overlap

When someone has a representation in only one modality, an early basic NLP intervention is to overlap from that modality to others, in order to add information from other senses. “When you hear those words in that tonality, what image comes to your mind?” “When you see that image, what sounds can you hear?” That kind of question is a deliberate instruction to elicit synesthesia in order to enrich someone’s experience by accessing relevant useful information that they may be ignoring. An image of a future event may look wonderful, but when you add in sounds and/or tactile kinesthetic feelings, it may be much less desirable. With more information, we always make decisions that are more accurate and balanced predictors of future satisfaction.

In everyday conversation we often speak of a sharp sound, a sour smell, a sweet spot, a flat color, or a loud shirt. While some of these expressions may be only metaphoric, often they indicate synesthesia that is below awareness, or on the edge of what we usually notice in our internal experience. For instance, when I hear music or voices, I always have a visual experience of abstract transparent 3-D shapes moving from left to right. Like any other skill, it has advantages and drawbacks. I have always preferred simpler melodies or small ensembles, because it is easier to visualize a smaller number of sounds. When there are too many sounds, as with a large orchestra or a big band, my images become cluttered, tangled and unpleasant. I also have trouble understanding conversations in noisy rooms, and if I’m looking for an address in unfamiliar territory, I need to turn the car radio off or I begin to have symptoms of ADHD.

To summarize, the widely accepted meaning of synesthesia is to experience two or more sensory perceptions simultaneously in the same location in space. This is an enrichment of experience that is generally useful, and only very rarely a problem.

 

What is the other definition of synesthesia?

In Robert Dilts’ Encyclopedia of NLP the entry titled Synesthesia states:

“Sometimes various sensations become connected and overlapped so completely that it is not possible to easily distinguish one from the other in a causal relationship. Feeling deeply moved by a piece of music would be an example of this. The feeling cannot really be distinguished or separated from the sound of the music. The same could be said for the sense of fear or pleasure that people experience when they see certain types of images.”

These “hear-feel” or “see-feel” causal linkages were called “fuzzy functions” in the early days of NLP. They are very important to us — sometimes problematic; sometimes very useful — but they are radically different from the previous definition of synesthesia in several ways:

  1. The causal relationship mentioned by Dilts presupposes a passage of time between the cause and effect, so the joining of the two sensations is sequential rather than simultaneous — even if it is very rapid.
  2. The two sensations are in different locations in space. The sound or image causing the feeling is typically heard or seen in a location outside the body, while the feeling is felt inside the body, mostly along the midline of the chest and/or belly. Even when the sound is heard in the ears, or the image is seen inside the head, that is still a very different location than the emotional feeling of “feeling moved,” “pleasure,” or “fear.”
  3. Finally, the emotional feeling in response to the sound or image is an evaluative feeling that is very different from a perceptual tactile feeling in the skin or fingers. Tactile feelings provide information about what is touched — its size, temperature, pressure, texture, etc. In contrast, emotional feelings provide information about the values of the person having the feelings.

This distinction between tactile and evaluative feelings is clearest when we have an evaluative feeling in response to a tactile feeling. If you are enjoying a loving touch, you experience both tactile feelings in the skin and underlying tissue (pressure, temperature, etc.) and also your emotional experience of enjoyment along the midline. But if someone unwelcome touched you in exactly the same way, you would have a very different emotional response to the same set of tactile sensations.

These three differences point out how very different this second definition of synesthesia is from the more widely accepted one. When a NLPer says that a client has a “synesthesia,” they are almost always using this second meaning of the word. They are also usually talking about a synesthesia that a client complains about because the resulting feeling is unpleasant, or has problematic consequences.

 

Does this distinction matter?

Since any ambiguity can lead to confusion, it’s always useful to be very clear what a word means, especially when the wider world has a different meaning for it. One way to avoid the ambiguity of the word “synesthesia” is to simply not use it at all, which is what Connirae and I have done for many years. Most clients who seek personal change do so because of unpleasant evaluative feelings. Since usually they have little or no awareness of how those feelings are generated by mostly unconscious visual images, auditory sounds, tactile feelings — and/or less often, smell or taste — we don’t find any advantage in using a special word for it. Furthermore the word “synesthesia” is a nominalization that turns a process into a noun, and tends to distract and obscure the specific sensory experience it refers to. Keeping in mind that the emotional feeling is in response to a perception or memory in one or more of the sensory modalities helps us focus on adjusting those in order to change the resulting feeling.

But before making any such adjustments, it’s important to think about the “problem” feeling in a wider context of space and time, to be sure that a change is “ecological.” A “bad” feeling of shame or guilt may be very useful in motivating us to make apologies or amends to repair a relationship that was damaged by something we did, or failed to do. If this positive function is not incorporated into any change, it will be very difficult to make any change, and it isn’t likely to last.

The flip side of this is that some “good” feelings lead to destructive consequences, such as overeating, drug use, or other compulsive behavior. In those cases it can be useful to make adjustments that result in “bad” feelings that are more useful in the larger context of space and time.

25 April 2017: Also see the followup to this blog post, Small Scope Synesthesia.