According to Wikipedia, "Overchoice... is a cognitive impairment in which people have a difficult time making a decision when faced with many options.” As long as therapists have an infinite choice of things they might do next, the result is bound to be distressing and confusing. This post is about how to make better choices more easily.
One common answer to the problem of overchoice is to follow a method or protocol. That does reduce therapist anxiety, but is limiting and rarely just right for the specifics of client and situation. In the 21st Century, we can do better. With today's understanding of foundational change processes and facilitative factors, clinical decision making can be narrowed down to meeting the requirements for those change processes, guided by the specifics of the person, the circumstances, and our personal repertoire of techniques. That’s why I have emphasized “process not method.”
That sounds good, but may still be a bit too abstract. In this post, I’m proposing relief on a more concrete level. What if we could focus our choices on a limited number of jobs or objectives? Over the past few posts, and with our class, I've been thinking about boiling the work of psychotherapy, regardless of school, down to a modest number of distinct tasks. I wind up with just eight of them. At any given moment, our focus and drive will be on one of them. The following sketches are meant to highlight each of the tasks, some of which have been detailed in recent posts. Within each of the eight tasks, there is room for constant learning and broadening of our repertoire.
Eight Therapeutic Jobs
1. Establishing and maintaining a positive and safe alliance
The alliance comes first because it is the first thing we focus on with each new client. It is also presented first because it is so critical in determining our success. Of all the objectives, this is probably the most complex, but, since it calls particularly on our ordinary social skills, as long as we are authentic, it can be handled with some ease. Perhaps the part that is the most challenging, especially to the beginner, is how to convey in what ways our role is different from family and social relationships. Doing so is critical to avoiding future trouble as we manage expectations and establish informed consent. Equally important at the start is giving as clear a picture as possible how the therapy will work and what the client should expect.
I considered safety as possibly an additional therapeutic focus, but I think preventing unnecessary hurt and ensuring informed consent are integrally entwined with managing expectations. Therefore, I consider our responsibility for client safety to be a part of managing the therapeutic relationship.
Over the course of therapy, clarification of expectations and potential problems helps also to lay groundwork for dealing effectively with future trouble spots. Success is greatly enhanced when a potential problem has been discussed before it happens. Along similar lines, one of the most important (and neglected) aspect of relationship management is monitoring how the client is feeling about the process. Listening and asking regularly may be unnatural, but are very helpful in dealing with the inevitable breaks before it’s too late.
2. Seeking our own understanding and working hypotheses
Here I’m talking about therapist understanding. The client may be ahead of us, with us, or behind us. Client awareness is the subject of the following section. Both tasks are also discussed in TIFT #33, Seeking Understanding and Awareness. Here, we are focused on making sense of what we see and learn.
I generally suggest three levels of inquiry. First I consider reality and try to understand the client’s complaints as problems due to troublesome reality. If that is enough to explain the trouble then the client has no need for more in-depth change. We may be able to help with good counsel alone. This is where psychotherapy has a greater component of counseling.
The next most benign kind of problem is developmental. Development happens when people try out and practice new behaviors. When they avoid or are shielded from experience, the result can be weak or missing components of development, and those can cause trouble. When all we have to do is help our client gain experience, the therapy may not be as difficult. Our work will be a matter of supporting motivation to take emotional risks and to interpret the results in a healthy way when things don’t work out as hoped.
Only when these two levels are insufficient to explain the problem, do I suggest going to the third level and looking for Entrenched Maladaptive Patterns (EMPs), the basic units of pathology treatable with psychotherapy. At this point, it is useful to be willing to form an opinion about what we think is maladaptive. In addition, we can follow our own curiosity about why this pattern is present and why it is entrenched, that is, resistant to change. Applying a bio-psycho-social model will help not to miss significant dimensions, as will one of the meta-theory frameworks such as Marquis’ Integral Psychotherapy or Henriques’ Tree of Knowledge.
My favorite idea-tools for seeking our own understanding are:
- Learn as much as you possibly can about the client’s initial complaint.
- Keep asking yourself what you don’t yet know.
- Assume that when you ask a question, the next action or words will somehow contain the answer.
Eventually, our notion of the problem will have to be squared with the client’s perceptions and wishes. Otherwise, we risk a rupture in the alliance if we pursue our goals without informed consent.
3. Leading our client to greater awareness and understanding
When we believe our understanding is ahead of the client’s our objective may be to lead them to a new level of emotional awareness. How hard we tug is an important matter of judgment. On the other hand, it may be best to refrain from leading at all and wait for the client to be ready. When feasible, helping increase clients' emotional awareness correlates strongly with therapeutic success. One reason is that awareness implies activation of the old pattern, and that is a prerequisite for the two change mechanisms of Extinction and for Memory Reconsolidation. A lot depends on the client’s general willingness or resistance to ideas brought forth by the therapist. Other problems include the client who accepts superficially, either in the childlike hope that pleasing the therapist will help or the more defensive stance of avoiding conflict.
Here, the discussion is about relatively mild ways of leading the motivated client to greater awareness. When clients reject our efforts or where resistance to change is more deeply entrenched, then our objective changes to #7, below, helping bring about structural change in thought, behavior, and/or values.
4. Supporting motivation
In TIFT #24. Jaak Panksepp and Motivation, Panksepp’s highly useful way of understanding motivation was described. In a few words, the SEEKING system is capable of attaching itself to any goal, short term or long, and sustaining efforts at attaining it. On the other hand, if the carrot is too far ahead of the donkey, the system may lose interest and move into depression. Thus, one of the main factors affecting client willingness to stick with the process and take emotional risks, is hope for a positive outcome.
Every therapy has ways of supporting motivation, whether overt or covert. Our active involvement has potential problems described in TIFT #35, but that is, in my view, more a reason to monitor the process with care, rather than to step back into “neutrality.”
Of all the ways to support motivation, helping the client to envision a desired outcome is probably the most powerful. In medicine, the goal is usually not to be sick. Since much of psychotherapy comes out of a medical tradition, we may tend to focus too much on the negative. Achieving a better life is likely to be a stronger source of motivation than not being sick. The more concrete the vision, the more powerful it may be in supporting motivation and success. Of course, when failure is a possibility, we need to be quite careful not to make or imply unrealistic promises.
Depending on attachment style, the therapist’s real emotional investment in the outcome can be a positive factor, but carries potential liabilities such as engaging childlike wishes to seek cure by pleasing the therapist or to seek independence by rebelling against the therapist.
Among other tools for supporting motivation, recognizing clients’ strengths, achievements, and progress tend to make those positives more “real,” and available to empower further progress.
5. Managing excessive arousal or “dysregulation”
When clients are in a state of dysregulation, blood flow to the thinking part of the brain shuts down and little therapeutic gain is to be had. Our job narrows to putting out the fire. These states are normal for children and our oldest ways of dealing with them come from experience as parents. First we need to calm ourselves, then focus on "containing" destructive behavior. Next, we begin lowering the temperature by showing our presence and calm, then helping the child or adult to share the cause of their distress so we can begin to experience accurate empathy.
More recently, researchers and clinicians began to look further afield. Stephen Porges’ Polyvagal Theory explained what was happening on a neurological basis and pointed to the principle that in an emergency we revert to our “lizard brain” then to our “monkey mind,” and finally to the human social mind. Daniel Siegel, Peter Levine, and others have bound clinical observation with neurophysiology to clarify these instinctive responses and how to calm them.
In particular, this new thinking has opened our field to soothing traditions from eastern practice. Smrti is a Sanskrit word appearing widely in Eastern thought. It refers to a kind of greater remembrance, a state of perspective or awareness, achieved simultaneously with direct experiencing, in other words, mindfulness. Type a keyword into any search engine and the internet will explode with techniques and approaches for those who seek to transform immediate distress via the wiser, broader kind of awareness that a mother brings to an upset child.
This was the subject of the first part of TIFT #34, Emotional Regulation and Awareness. That post also relates to #6, just below in our list.
6. Healing specific emotions
“Affect” means conscious feeling accompanied by bodily changes. That interesting combination is how therapists know that deep emotions are in an active state. Those deep emotional centers are analogous between humans and in other mammals. The strange thing is that we can’t actually know what they feel like. We think we know what our dog feels and, in the same way, what our infant is feeling. However, many researchers insist that we can’t know what animals are feeling, because consciousness adds an important layer of mental and linguistic processing that is essentially unavailable to animals and infants. Furthermore, it is clear that these deep emotions can exist without any conscious awareness at all. What can we do with all this confusing complexity?
One simplifying concept, with which no one seems to disagree, is as that, as far as we know, all responses to potential threats are triggered by these deep emotions. Since the EMPs (Entrenched Maladaptive Patterns), that are the main focus of psychotherapy, represent responses to potential threats, then they, too, can be thought of as triggered by deep emotions. When they reach consciousness as dreaded affects, our clients want relief. Preferring normal English, the word I use for lasting or even permanent relief is “healing.” How activation of deep emotional circuits is necessary for emotional healing is the subject of TIFT #34, mentioned above. To summarize, Extinction and Memory Reconsolidation are able to inhibit or transform problem responses though the influence of a surprising “antidote,” which is usually the calming perspective (Smrti) mentioned in the previous section on arousal regulation. How is it that the healing a painful emotion converges with helping clients who are dysregulated? Peter Levine describes it well when he points out that, as the calming of dysregulation proceeds, the client begins to be able to use their more advanced social capacities. What that means is that they are able to communicate the source of their distress and to receive the broader, empathic understanding of another human being. Thus, the endpoint of “re-regulation” and the healing of specific dreaded affects are really the same.
7. Supporting voluntary change of thought, behavior, and values
Two previous posts have addressed this job. The first is TIFT #35 on changing thought and behavior. While thinking about basic therapist jobs. I realized that the techniques we use for helping clients change values (including also, attitudes, ideals and prohibitions) are really the same. The difference is that values are harder to change, and, actually, can only be modified by the internalization of new ones that take precedence over the old. That is what is described in more detail in TIFT #9, "What You Don’t Know About Shame."
8. Working with inner selves (transference)
Those who have been reading my posts are aware that I have mostly traded the old concept of transference for the idea of an inner child or self. The reason for the change is that transference tends to make one think of a static distortion in perception. The reality is far richer. In practice, we are dealing with a purposeful, even strong-willed, agency of the mind that has its own ways of thinking, motivation, and ways of solving what it sees as problems. I often use the “inner child” to capture childlike thinking and methods, but as pointed out in TIFT #2, every inner child is an individual.
One key to this task of therapy is that clients usually have a negative attitude towards their immature patterns. They want to eliminate or even punish the inner self. Of course that is one of the surest ways to prevent growth. Identifying an inner child helps clients adopt a more accepting and empathic attitude.
Another key concept is understanding that our job as therapists is to help the inner child accept a radically new and different solution to the problem that has been the child’s main concern since going “underground." A good metaphor for this is that the child has always lived in a one-story “ranch” house. While the child is familiar with all the rooms in the house, the therapist brings news that, in fact, there is another floor above. We bring a new way of solving the problem, through acceptance. This is shocking to the child, since acceptance is what they have rejected at every turn. Why do children reject that solution? Acceptance is painful, but even worse, it means letting the grown-ups off the hook. They were reluctant to do their part in solving the problem in the first place, so the child expects the therapist to be reluctant as well. Indeed, we are reluctant to solve the client's problem, all the more since we can't. When we propose accepting parental failures of the past, it sounds to the child like nothing but a “cop out,” with the therapist abdicating the job and offering only pain in trade. We have to help the inner self come to experience acceptance and realize that it actually feels better. Simultaneously we need to help the child realize that the therapist really cannot solve the problem, leading to further acceptance. This difficult transformation is the true subject of many of the comments in my blog over the years.
Eight is a lot, but, I hope, far less scary than an undetermined, and therefore infinite choice of possible objectives and strategies. So far, I think these eight cover the bases at the level of things we might consciously focus on accomplishing. At the beginning of a session, we will often be conscious of which of these is our priority. As the session unfolds, other jobs may need to be attended to and the focus may change, but I don’t think it will go outside the eight jobs described here. So I hope in the end that this list offers an antidote to the scourge of therapist overchoice.
Jeffery Smith MD