© 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.”

 

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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.