TIFT #27. Knowing What You Don't Know

tift Aug 31, 2021


In In TIFT #25, “The Quest in a Question,” we looked at how questions can engage three basic human systems: interpersonal connection, motivation, and the nonconscious problem solver’s impressive power to point towards the answer. In this post, we look at how to know what questions to raise. There is one powerful key: being clear about what you don’t know.

When you are specific about what you don’t yet know, you will naturally formulate the kind of question that shows you are in tune with your patient’s specific issues, that you are genuinely interested, and that you have focus and direction in guiding the patient’s therapy.

How to know what you don’t know

The more clear you are about what you do know, the more specific you can be about what you don’t know. This means having a working hypothesis with as much detail as possible. The secret path to good questions is a constant striving to state for yourself exactly what you think is going on, that is, a “formulation.” Therapists often view formulation as a dry exercise for trainees in which they create a psycho-babble explanation using the jargon of whatever orientation they have chosen. In fact, insisting on having a working hypothesis to explain the patient’s problems is not only helpful with the present therapy, but an excellent way to keep learning about how humans adapt. Recalling that this is only a hypothesis and may turn out to be wrong, each intervention arising from your hypothesis becomes a test that will help confirm or falsify your thinking.

A triggering emotion and an emotion-lowering behavior pattern

The concept of EMPs, Entrenched Maladaptive Patterns, provides a universal framework applicable to the huge variety of problems treatable in psychotherapy. Here are some common features that can be found in every EMP:

  • They all represent responses to (consciously or unconsciously) appraised threats.
  • They are aimed at minimizing or avoiding the core emotions that trigger them. These emotions may be experienced consciously as affects, that is, feelings with bodily changes.
  • They all consist of patterns of behavior, defined broadly to include automatic thoughts, actions, impulses, feelings, and bodily changes. 
  • In addition, EMPs may include voluntarily chosen but maladaptive responses to the above automatic feelings, thoughts, etc. that pop into consciousness.

To simplify, EMPs work like a refrigerator. When the thermostat registers too much warmth (deep emotion, conscious or not), it goes to work (behavior) to lower the temperature. When we have a clear idea of what emotion the pattern is aimed at lowering and how it accomplishes that goal, then we have a good working hypothesis to explain the patient’s problem. Thus each unit of pathology boils down to a triggering emotion and an emotion-lowering behavior pattern.

Testing our formulation: Differential diagnosis

Having a working hypothesis is good. Having a list of possibilities is even better. Please forgive me for introducing another technical phrase. “Differential diagnosis” in medicine means making a list of possible diagnoses in the order of their likelihood. That way, if your first idea turns out to be wrong, you will still have a working hypothesis. Armed with as complete a list as possible, you can bring to bear the process of elimination. This powerful logic will help you home in on the real truth. If it’s not A, then it must be B or C. Rather than just asking yourself if the patient’s responses to your interventions support your formulation, you can now ask if the response is more consistent with one of the alternative explanations. Of course your list of possibilities may be incomplete. You may have missed the one that turns out to be correct. The more you insist on listing all possible explanations, the better you will become at being inclusive. In the end, the more clear you are about what you know, the more clearly you will see what you don’t know.


The next step in formulating what you think you know is looking at resistance. Actually it is useful (and really neat) to think of resistance as a new layer of EMP, created specifically to deal with the perceived danger that the therapy might uncover a difficult emotion by taking away a valued protection. That means resistance has the same universal EMP structure consisting of a dreaded emotion and an avoidant behavior pattern. What would the patient be afraid of feeling as a result of therapy and how is that feeling being avoided?

What we don’t know

At any point in the process, many of these elements will be unknown but now we have a very clear and sharp idea of what it is we are looking for. In addition to the troublesome emotion, the emotion-lowering behavior pattern, and how change is being resisted, it is often useful to think about at the origins and cognitive level of a pattern as well. Here I summarize some of these elements:

  • What is the EMP that is causing trouble?
  • What is/was it designed to avoid?
  • How does it work to accomplish avoidance?
  • What might be an improved way to cope for this patient?
  • What is the emotional work that would make the EMP unnecessary?
  • What resistance EMP is working against progress?
  • When and how did the EMP first come into use? 
  • What was the cognitive or developmental level at the time?
  • What part(s) of this structure are most accessible right now?
  • What might be the best way to approach this most accessible aspect of the work?

These may look like a lot of questions, but each one represents an important facet of the patient’s trouble and its cure. As one becomes familiar with the elements, they will be relevant for every patient and every problem. Knowing the elements of a complete EMP formulation, it becomes quite natural to home in on the next missing piece. Armed with clarity about what you don't know, you will naturally raise the right question at the right time, setting off an exciting new quest.

This description is quite abstract and readers are welcome to contribute examples. Comments are invited on the blog post version at www.howtherapyworks.com.

Jeffery Smith MD 

Photo: nik-shuliahin-cp1k4Cmx4OE-unsplash.

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