In the early 70s, I was taught mostly to keep my mouth shut when doing psychotherapy. In fact, one residency didn’t select me because they saw (correctly) that staying quiet would be a real challenge. Fortunately I did match with a great residency, Albert Einstein, where my best supervisor said, “Mix it up with the patient.” But many teachers still believe in a relatively withholding therapist. This post is about the effects of one kind of active intervention, asking questions. We’ll take a deeper dive into the art of questioning to show why this form of active intervention seems particularly rewarding. It’s a story of empathy, mirror neurons, oxytocin, and the SEEKING system.
Every question is a story
I’m not talking about factual questions like “Do you have brothers or sisters,” but questions where, at the time of asking, neither of us knows the answer. These questions turn out to embody the same elements as a well told story. First they catch our attention in an emotional way, Then, they allow us to follow the well worn path of identifying with the protagonists, experiencing roadblocks, and finally enjoying the satisfaction of success.
Let’s take an example. A man has an affair, and is caught. He decides that he really values his marriage, but finds himself re-contacting the girlfriend to the great distress of his wife and himself. The question is why? Why does he repeatedly reach out to the girlfriend? He recognizes that doing so is cruel to her, keeping her hopes up, and severely destructive to his own goal of regaining credibility in his marriage. Let’s look at some aspects that give this question the elements of a story.
Writers call this the “hook.” Without catching the patient’s attention there won’t be significant engagement and the magic of storytelling won’t take hold. As therapists, we have a big advantage. Learning about oneself is of passionate interest. The fact that the answer is not known adds to the intrigue, so we are in good shape. Even more important, as in our example, a question about the patient’s most concerning problem raises intense emotion.
Identification with the protagonists
That’s easy. The therapeutic relationship is a partnership, meaning that the patient identifies with him or herself and with you the therapist. We are both heroes. Empathy for each other increases oxytocin in the brain, and that encourages both trust, and warm feelings towards the protagonist duo.
These warm feelings are particularly important therapeutically. Patients are naturally angry with themselves about maladaptive behavior. They need to develop understanding and compassion for the part of their own mind that is getting them in trouble. As with children, a harsh, judgmental attitude is counterproductive. Identification with the therapist’s curiosity and interest leads the patient to be more open and accepting. Where patients may experience themselves as the enemy of their own unruly impulses, partnership in a joint quest tends to turn antagonism into love, which is much more effective.
Encountering adversity and challenge
Storytellers work so hard to invent hurdles that the protagonists must overcome. In this case, a major obstacle is ready-made. Necessarily the answer will be hard to find. Entrenched Maladaptive Patterns are, by their nature, baffling. They bring up hard questions and we naturally want to understand why.
Now that the patient is emotionally invested and the mind is focused on a challenging goal. The SEEKING system is engaged. This is the dopamine-fueled brain motivational system described by Jaak Panksepp (TIFT #24) as a system that can attach itself to any goal and gives intense pleasure in its pursuit.
Not only does the quest for an answer give pleasure, it also enlists the nonconscious problem solver. In a previous post (TIFT #22), on unconscious thinking, I talked about how, especially during sleep, the unconscious mind goes to work using its power of metaphor building to find its way to the solution. Freud was banking on this when he used free associations produced by the unconscious mind to get a glimpse of what was going on in the unconscious.
In practice, once we ask a question, we can rely on the unconscious to begin immediately scanning memory banks for associations and connections. The hope of finding the treasure is what continues to keep dopamine levels and engagement high.
When patients try to reason their way to an answer, the results are usually disappointing. The resulting ideas are typically intellectual and of little use. The valuable clues are those associations that “resonate” or bring up some emotional element. They often appear unexpectedly in the course of conversation. Having unleashed the remarkable problem solving power of a motivated unconscious, we can count on these clues. The challenging part is to catch them and understand their significance. In the example above, the patient who re-contacted his girlfriend, one statement repeated a few times, was the clincher. The patient continued to express doubt that his wife would ever forgive him. His thought was clearly not true. Forgiving him was explicitly what she most wanted. I asked myself why he might persist in believing the opposite.
The ultimate reward for the quest, and the thing that makes us want to do it again, is coming to a satisfying ending. However, when it comes to knowing the unconscious, all we have is indirect evidence. The beauty of asking a question like, “Why do you keep contacting your girlfriend,” is that the answer, even if uncertain, represents a genuinely testable hypothesis.
The fact that the patient persisted in believing his wife to be unforgiving was a clue that he was not seeing her as she is, but through colored glasses, influenced by something in his past. I had already formed a hypothesis that he had been forced into premature adulthood at age 10 and carried an unconscious resentment towards his mother, whom he saw as the one who unfairly and uncaringly denied him the innocence of childhood. The misperception of his wife was a classic transference in which he saw her as he had seen his mother many years earlier. So his contacting the girlfriend was in revolt against the closed-minded and unforgiving woman his unconscious saw in place of his wife.
This new insight was testable, and passed the first tests. It did resonate and, more importantly, led to a breakthrough in months of resistance to change in behavior.
I hope that this begins to make clear how questions can tap into the same power as storytelling to awaken important built-in, instinctive brain systems. Engaging those systems can both strengthen the alliance and lead to testable hypotheses. Are there disadvantages? Yes, it is possible for the questioning to lead to intellectualization, which won’t help. It is also possible to raise questions before the patient is ready to discover the answers. Other than those, I have not encountered negatives.
Here, then, are some concrete reasons for “mixing it up with the patient.” Over the years, I have followed my instinct to be active and have been a better therapist as a result. Next time we’ll take a look at how best to identify and ask the kinds of questions that can lead to an exciting story and to the results you and your patient both want.
Jeffery Smith MD
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