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 He’s withdrawn from interacting with me, my sister, and his grandchildren. He’s even withdrawn from my mom.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.”