Friday, March 5, 2010

Listening & Connecting

Reading Yalom taught me to be a psychotherapist using a humanistic-existentialist approach. Carl Rogers, master therapist and theorist, also described himself as humanistic and existentialist. I learned skills for connecting using his person-centered approach (active listening skills).

When we listen to clients and their stories and witness their pain, we have an urge to change, fix, minimize or deny their feelings (don't feel that way, look on the bright side, don't cry, it's not so bad). Empathic listening is powerful and leaves clients feeling understood - ultimately very healing.

"Listen to your patients; let them teach you. To grow wise you must remain a student." --Professor John Whitehorn from Momma and the Meaning of Life by Irvin Yalom.

Yalom describes the work of his mentor: "Dr. Whitehorn related to the person, rather than the pathology, of that patient. His strategy invariably enhanced both the patient's self-regard and his or her willingness to be self-revealing...There was no duplicity: Dr. Whitehorn genuinely wanted to be taught...'You and your patients both win,' he would say, 'if you let them teach you enough about their lives and interests. Learn about their lives; you will not only be edified but you will ultimately learn all you need to know about their illness.' "

Yalom asks a client at termination: "Tell me, from your perspective, what was the real center, the core of our work?"
Patient responds: "Engagement," she said at once. "You were always there, leaning forward, getting closer."
Yalom: "In your face, you mean?"
Patient: "Right! But in a good way. And not in any fancy metaphysical way. I needed just one thing: for you to stay with me and be willing to expose yourself to the lethal stuff radiating from me. That was your task. Therapists don't generally understand this. No one but you could do this. My friends couldn't stay with me. They themselves were too busy grieving for Jack, or distancing themselves from the ooze, or burying the fear of their own deaths, or demanding - and I do mean demanding - that I feel okay after the first year. That's what you really did best. You had good staying power. You hung in there close to me. More than just staying close, you kept pushing for more and more, urging me to talk about everything, no matter how macabre. And if I didn't, you were likely to guess - pretty accurately, I'll hand it to you - what I was feeling. And your actions were important - words alone wouldn't have done it. That's why one of the best single things you did was to tell me I had to see you an extra session every time I got really engaged with you."
Yalom: Other helpful things?
Patient: "Again simple things. You may not even remember, but at the end of one of our very first sessions, as I was walking out the door, you put your hand on my shoulder and said, 'I'll see this through with you.' I never forgot that statement - it was a mighty staff of support."
Yalom: "I remember, Irene."
Patient: "And it helped a lot when sometimes you'd stop trying to fix or to analyze or interpret me and you'd say something simple and straight like, 'Irene, you're going through a nightmare - one of the worst I can imagine.' And the best thing of all was when you'd add - not often enough - that you admired and respected me for my courage in persevering."

Yalom summarizes his approach using the here-and-now:
"I bridled at such simplification. Surely my approach to therapy was more complex and sophisticated! But the more I thought about it, the more I came to see that Irene had it quite right.

For sure she was right about 'engagement' - the key concept in my psychotherapy. I had decided at the very onset that engagement was the most effective thing I could offer Irene. And that did not simply mean listening well, or encouraging catharsis, or consoling her. It meant rather that I would get as close as I could to her, that I would focus on the 'space between us' (a phrase I used in virtually every hour I saw Irene), on the 'here and now': that is, on the relationship between her and me here (in this office) and now (in the immediate moment.).

Now, it is one thing to focus on the here-and-now with patients who seek therapy because of relationship problems but another matter completely for me to have asked Irene to examine the here-and-now. Think of it: Is it not both absurd and churlish to expect a woman in extremis (a woman whose husband lay dying of a brain tumor, who was also grieving for a mother, a father, a brother, a godson) to turn her attention to the most minute nuances of a relationship with a professional she hardly knows?

Nonetheless, that was just what I did. I began it in the first sessions and never relented. In every session, without fail, I inquired about some aspect of our relationship. 'How lonely do you feel in the room with me?' 'How far from, how close to me do you feel today?' If she said, as she often did, 'I feel miles away,' I was sure to address that feeling directly. 'At what precise point of our session did you first notice that today?' Or, 'What did I say or do to increase the distance?' And most of all, 'What can we do to reduce it?'

Throughout our therapy I was dogged about engagement. I refused to be pushed away. To her, 'I'm numb; I don't want to talk; I don't know why I'm here today,' I responded with some comment such as, 'But you are here. Some part of you wants to be here, and I want to talk to that part today.'

Ordinarily the here-and-now focus in psychotherapy has many advantages. It imparts a sense of immediacy to the therapy session. It provides more accurate data than relying on patients' imperfect and ever-shifting views of the past. Since one's mode of relating in the here-and-now is a social microcosm of one's mode of relating to others, both past and present, one's problems in relating are immediately revealed, in living color, as the relationship with the therapist unfurls. Furthermore, therapy becomes more intense, more electric - no individual or group session focusing on the here-and-now is ever dull. Moreover, the here-and-now provides a laboratory, a safe arena, in which a patient can experiment with new behaviors before trying them in the world outside.

Even more important than all these benefits, the here-and-now approach also accelerated the development of a deep intimacy between us. Irene's outward demeanor - frosty, forbidding, supremely competent and confident - kept others from approaching her. This was precisely what happened when I placed her in a six-month therapy group at the time that her husband was dying. Though Irene quickly won the members' respect and provided considerable support to others, she received little in return. Her air of supreme self-sufficiency told the other group members she needed nothing from them.

Only her husband had cut through her formidable demeanor; only he had challenged her and demanded a deep, intimate encounter. And it was only with him that she could weep and give voice to the young lost girl within her. And with Jack's death she lost that touchstone of intimacy. I knew it was presumptuous, but I wanted to become that touchstone for her...Gradually, very gradually, she was able to acknowledge feelings of helplessness and to turn to me for comfort."

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