Despite the century long history of psychotherapy in this country people frequently ask me what happens in a session, how to tell if the process is working. Here’s an example of a decent session with Simon, someone I wrote about in a recent blog entry. You’ll remember this was a very bright, accomplished, but highly intellectualized young man who came in complaining of panic attacks, obsessing, indecision. In particular, he had trouble understanding how he had been so independent until about age 20, and then seemed to “crash”.
He came in one day struggling – agonizing, really – over what to talk about. This is a common occurrence even with experienced patients. Everything he started to discuss petered out. For example, he told me that he was worried about his apparent loss of motivation. He said he used to stay up late doing research and reading in his field, but lately preferred to socialize. I asked when he had last felt motivated, however, and he told me that just two nights earlier he had in fact stayed up and worked. Then I asked him when he last had a sustained period of such behavior, and he could not answer. I asked him about the work he stayed up doing and he could not even answer whether he was in fact interested in the project or not. He started to say “yes”, then corrected himself to say “well, it might be something that later on…”, then said again “yes”, then added “hmm. I don’t know why I can’t answer”.
At this point I interrupted with the observation that thus far in the session he was unable to answer almost any of my questions without a great deal of hedging and at times muttering inaudibly as if in some private reminiscence. He acknowledged this, relaxed a bit, and then tried to focus on the question that is always useful one: What is of interest to you right now? What are you feeling or thinking about right now?
He answered, feeling silly, “I’d like to be somewhere warm”.
Trivial as this bit of information may appear at first, here is where the session really began. If that seems hard to swallow, hang on for a few paragraphs. Unlike everything else he said, this was a statement without hesitation or backpedaling, which clearly expressed his feelings and his interests. At this point we can begin to find out something about him, his functioning, his issues, etc. Consider the possibilities:
1) We might discover with further questioning that his fantasy is to be in the Caribbean. Further inquiry might reveal that the fantasy is one of escaping pressures, that he is troubled by his job, his love life, his friends, etc., i.e. that being cold or warm is not even the issue but that escape from stress and pressure is. He might be lonely, pressured at work, unsure about handling difficult people, or something else. At that point, clearly we have plenty to talk about some of which would very possibly resolve in a single session – how to handle a difficult boss, colleague, lover, work load, etc.
2) Simon might tell us of a Caribbean fantasy involving water sports. Further inquiry might reveal that his problems could be solved by getting some exercise, that he has been gluing himself too persistently to his desk and needs to take a run.
3) Simon might tell us that his fantasy is literally to be warm, at which point the question becomes why doesn’t he put on another sweater or turn up the heat.
This last possibility is the one Simon voiced. Without my asking anything, however, he then speculated as to why he had been sitting not only during our session but all morning (we spoke at noon) in a cold apartment. He then realized with frustration that he had not turned up the heat because of a preposterous concern with the heating bill. He did a quick calculation and told me that the morning’s heat would’ve cost him less than a dollar.
From here, Simon continued to talk about the way he’d spend the day so far and noted that all morning he had been in his words “worried about what I should do and doing none of it”. He had made a list of chores, projects for work, and some long-term goals, then had rethought these several times until before he knew it the morning was gone. Moreover, all the while he was aware of being cold – had even looked online at some sweaters and warm slippers he might buy, then decided against it because of the price and mainly because “I shouldn’t need those things”.
At this point he articulated what had been barely conscious to him all morning although was apparent in how he spoke at the start of our session: “I get consumed with whether what I’m thinking, what I want, what I feel, is okay, if it looks cool, like how would this look to me if I read it about me” and so on. He then noted that his entire week had been dominated by such concerns with what he should and should not feel, think, want, do. This brought us back to where we had been the previous weeks, to discoveries and insights that have been brewing and consolidating in recent sessions in which Simon was realizing the degree to which he moved through the world in a state of apology, anxiety, insecurity, and indecision.
All this emerged because I got him to stop fidgeting and answer the question “What’s on your mind right now (however apparently trivial)?” After that I didn’t have to say much. The simple statement of where he was at – that he wanted to be warmer – got him back in touch with everything else about him and it all came pouring out, including a cheerful frustration with having wasted the day being cold when for the price of half a cup of coffee he could have worked in a comfortable home. (He also mentioned at that point his complaint – something he never dared pay attention to – that his tea had become cold; we laughed at this brilliant Ivy League graduate not thinking to warm it the microwave.)
Amid this burst of insight, one of the things Simon said was “if I realize that I like it warm, what will I do when I can’t be warm in the house? It’s like I have to get used to it so I’ll be okay when it’s taken from me.” I did ask him to stop and take note of that issue – the idea that things will be taken from him – and see if it brought up any other thoughts. He immediately mentioned his father becoming very ill when Simon was quite young. From there he spoke about other memories that brought on that feeling of profound insecurity, of having to be entirely self-sufficient to the point of not even using heat or a sweater if he could possibly avoid such dependency. Amid all this, he calmed, made some decisions about his day and future without so much obsessing and anxiety, and ended the session feeling much better than he had at the start of it.
All of this demonstrates several important features of psychotherapy. First, there really is nothing else to do until you answer the question “where are you at today? what’s on your mind now? what’s of interest to you?” It seems simple, but people sometimes have great difficulty simply starting here. Second, once you relax and let yourself consider that question everything about you can come out and be addressed – issues as immediate and trivial as physical comfort, as pervasively interfering as a neurotic preoccupation with perfectionism, and as deep as childhood trauma.
Third, this session answers in part the question I’ve so often heard over the years, “How can you listen to people’s problems all day? Don’t you get bored?” In fact, it’s life outside the office that can, by comparison, be dull. Think about it. If I were chatting with Simon in a pub and he was waffling as he was at the start of our meeting, it would be difficult to point out that he was rambling; I might have to listen to more of it and find some graceful way of ending the conversation, particularly if we weren’t more than casual friends. But in psychotherapy it’s my job to point out to Simon what I see going on, that he’s hedging, drifting away in the middle of saying something, and ultimately saying nothing, in short avoiding any substantive talk and thus boring us. As result of my speaking up, Simon came to life and the session became exciting for both of us. Outside my office, in some other social settings, telling someone that he’s boring you can be offensive (and one does not want to offend a man in his late 20s who lifts weights for recreation)