Psychotherapy is often called “the talking cure,” and talking is certainly part of it. However, one of the few solid findings from research is that the relationship between therapist and client is a much more important part. Often this is described with a vague general term such as “rapport” or “alliance,” but seldom does anyone describe or teach the exchange of specific behaviors and responses that create this relationship.

Noticing and responding to specific nonverbal communication is the key to eliciting more useful responses in the client. Talking may be the backbone of therapy, but the nonverbal exchange is the flesh and blood that brings it to life. In this post I offer you a short video that illustrates a number of important elements in this mostly unconscious dance.

Rich Simon, editor of Psychotherapy Networker magazine, has been creating a number of video webcasts (qualifying for CEUs) in which several therapists each discuss their approach to a particular problem or outcome. To interest people in signing up for these, he has been posting a very short clip from each webcast set. Most of these clips are unremarkable, and only useful to get a sense of how different therapists think about what they do.

However, I think the video clip of Diana Fosha below is much more interesting than most, and offers rich examples of nonverbal communication that illustrates some very important principles. I learned a lot from going it over carefully — and repeatedly.

To sensitize yourself to Diana’s nonverbal gestures even more, first watch the 3-minute clip with the sound off, and then with the sound on. Particularly notice how she punctuates each word or phrase with her head movements, and notice how distinct her hand gestures are. They don’t simply flail around in space, or repeat the same gestures over and over; they congruently amplify and clarify what she is talking about. My words can only point out aspects of her nonverbal behavior — observing the behavior itself is what is useful. I strongly encourage you to watch the clip before reading further — find out how much you can observe and learn before reading my comments.

http://youtu.be/LMiCYi71uRQ

I’m sure that Diana’s definitive and expressive gestures are a very important part of how she connects well with clients. Nearly everything she says is accompanied by nonverbal gestures that eloquently and unconsciously amplify what she is saying. I will only be focusing and commenting on a few of them that illustrate important principles.

For instance, notice how she gestures toward herself with her right hand at 0:30 just before she says, “You know, the many people who end up having these implicit (positive) moments that we’re talking about” and then changes her hand gesture as she says “but,” (0:37) clearly separating the contrasting thought that follows. Then she gestures with both hands to the left and right of her head as she says, (0:39) “Their internal working model remains” (0:42). Her hand gestures change again to point more to herself as she says, “or their ideas about themselves.” Then her forefingers point to each other as she says, “and how they relate” (0:47). Then she points to her left (0:46) with both forefingers and then says, “are based on the old stuff,” indicating that she stores her past images to her left, as many people do.

Notice that this last gesture precedes her saying “old stuff,” by about two seconds, giving the viewer immediate information about how she is processing internally, and giving advance notice of what she is likely to say next. This gesture also indicates that she is identifying with the client she is talking about, which is far more convincing than a general verbal comment such as, “Yes, I know what you mean.”

Although a few of her gestures are at the same time as the words they clarify, most of them precede her words by a second or two. Her unconscious processing communicates directly with your unconscious about 2 seconds before the conscious communication. In contrast, many therapists’ communication is almost devoid of nonverbal gestures and other expressions, so it is primarily verbal and conscious. Conscious communication alone is dry and intellectual, and doesn’t elicit unconscious responses, so it is mostly a waste of time.

Here is another example: After she says, “Even though we had a nice moment,” at 0:55, she gestures with her right hand over her right shoulder, to indicate that the nice moment gets thrown away. Again the nonverbal communication is clear and elegant, and precedes the verbal description.

The words that follow, “Then by the time you walk out of the office” are somewhat vague, but their meaning is specified by her right hand first repeating the over the shoulder discarding gesture, and then pantomiming zipping up a jacket, followed by the nice metaphor, “zip up, close up the jacket, emotionally,” at 1:00 during which she repeats the zipping up gesture twice. Then she gestures toward herself as she again identifies with the client she is talking about, quoting the client’s thoughts, (1:03) “I still think ‘I’m a lone wolf,’ or ‘People don’t touch me emotionally,’ or ‘Nobody wants to have anything to do with me,’ or whatever.”

At 1:35 she repeats her gesture with both hands on both sides of her head as she says, “Their internal working model doesn’t change — how one sees oneself relative to other people, doesn’t really change.” (1:38)

When I work with clients I am always working directly with their “working model,” usually with the submodalities of their internal experience — the location, intensity, and other sensory qualities of their internal images and voices.

The client’s self-concept — the way they generalize about themselves — is a very important part of that model, which I have written about in great detail in my book, Transforming Your Self: becoming who you want to be.

At 1:42 she gestures with thumb and forefinger very close together, saying, “That’s why I take very small bits.” Then she spreads her thumb and forefinger much farther apart (1:49) and says, “Because if you take big bits” — by which she means larger generalizations, in contrast to a specific experience—her over-the-shoulder gesture again communicates that it will be discarded. Rich Simon nicely responds with the same over-the-shoulder gesture, indicating that he already understands the gist of what she will say next. Notice that her small head gesture to her right and behind a couple of seconds earlier at 1:47 give you advance notice of her hand gesture to follow.

Another way to describe this is that Diana’s nonverbal expressiveness is fully congruent with her verbal description, and the nonverbal message precedes the verbal. The same will be true of incongruent communication — the nonverbal will usually precede the verbal, and it will contradict it, resulting in lack of rapport, confusion, etc.

Although this clip is of a therapist describing her work, the same principles apply to a client’s behavior. Nonverbally and unconsciously they will give you advance notice of the general nature of what they will say next with their gestures and other nonverbal responses. If you are sensitive to this, your nonverbal response to this can establish an unconscious rapport that is a key to eliciting new and more useful responses in the client. Though some clients are much more expressive than others, ideally the therapist should be able to notice the general nature of the client’s response before they say anything.

I wish Diana had been somewhat more specific in describing how to help the client generalize the useful moments in therapy to the larger context in the real world, and to their self-concept. For instance, when she says at 2:05 “And start to help the person have an experience of what it actually feels like to be connected,” that is a good starting point for a useful generalization. It can be very useful to mark out such an experience to make it more memorable, by saying something like, “I want you to take some time to quietly savor this experience fully and remember how it feels, because I’m sure that it can be a powerful resource to you at many other times in your life,” or “I want you to remember this experience in every cell in your body, so that you couldn’t possibly forget it, and so that you can have the choice to experience it again whenever and wherever it serves you.”

When Diana says at 1:05, “Hmmn, that takes a lot of courage,” that is a useful way to take a moment in therapy and make it into a larger generalization about the self. When it is part of the self, it will become part of the client as a consistent belief and attitude that goes across a multitude of contexts, rather than as only an isolated response in a particular time and place. A somewhat more explicit way to strengthen the client’s self-concept is to say something like, “What does it say about you as a person that you have had this feeling of being connected with me in this room?” or “So you are someone who can realize when you are connected with someone else.”

A useful next step is to empower the client by asking them, “What did you do — consciously or unconsciously — that made it possible for you to have this experience?” Any answer to that question will alert them to what they can do to be more active in creating their experience, and have more of the kind of life they want.

A further step is to explicitly take this resource experience — either a specific experience, or a self-concept generalization about themselves based on the experience — and rehearse it in the specific contexts where it will be useful in the future. “And can you imagine now what it would be like to have this feeling of connection in those difficult moments with your wife? Take this experience into a likely future example of one of those times, and find out how well it works to shift your response in a way that you like and find useful.”

I imagine that Diana would fully agree with all these later comments, but I thought it would be useful to describe them clearly and explicitly, so that they can become a more memorable guide to how you, the reader, can work more effectively and efficiently with clients.

I emailed Diana, asking her if she would look this post over, and let me know if she would like to make any changes in it, or offer any other response. She replied as follows:

“I am fine with what you wrote and, as you guessed I would, I’m in agreement with your elaborations as follow-up on some of the points I made in my conversation with Rich. I make it a point in those dialogues to be in conversation mode rather than in presentation/teaching mode, so of course a lot gets left out.” Diana Fosha: http://www.aedpinstitute.org

Postscript
I have heard that when someone once asked Milton Erickson (probably the greatest therapist who ever lived) if he was aware of the impact on his clients of his head position and movements, he responded as follows (while moving his head):

“In nineteen hundred and thirty-two,…I systematically varied the position…and movements of my head,…and noticed their impact on my clients…and when I understood it thoroughly,…I forgot it.” (consciously)

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