Jeff Levy, LCSW
Mental Health, Relationships, Trauma, Identity
Jeff Levy, LCSW
(originally posted on Branching Out: The Live Oak Blog, and Linked In, December 2017)
I was recently thinking about sessions over the course of the last few weeks that went smoothly, and those where I felt like we hit some bumps or that we stalled. I tried to remember the things I did or questions I asked that I thought helped all of us in the room feel some movement. There were many ideas and questions I jotted down, but five stood out to me as particularly helpful.
While I know there are no quick fixes to change the direction of a session that feels like it is stalled, I still look for strategies to support people in making the changes that bring them to my office, even in the context of a single session. Maybe it’s unrealistic to think that lasting change can happen in a session. But I believe there are ways we can invite ourselves and our clients to consider intentional shifts, even in the context of a single session.
What’s happening on the inside?
A few years ago, one of my posts talked about “the weekly report.” I wrote about those of us that start our sessions by talking about what’s happened during the previous week. In some instances, this takes the form of a day-by-day description of the week’s events. Other times, it includes highlights from the prior week. While there is definitely utility in hearing about the week, it’s inevitable that at some point we will hear: “Well, nothing new really happened this week.”
Nick frequently begins his sessions with a run down of the prior week’s events and activities. He initially sought therapy to address a 15-year marriage where the romance had disappeared after just a few years. From the time we began therapy, he told me he and his husband rarely discussed their relationship and had settled into a rhythm of activities that no longer included sex.
It soon occurred to me that Nick and I had also settled into a rhythm of discussing the week’s activities without a deeper exploration of his relationship with his husband. While he often talked about what social activities he and his husband had engaged in during the week, there was no mention of any physical contact—even loving contact that wasn’t necessarily physical.
Last week, Nick sat down in my office and looked at me with mild discomfort. I had a sense that meant that he didn’t know where to start, and sure enough, he began the session with the anticipated: “Well, nothing new happened this week.”
Typically, when our sessions began this way, I wonder if they will feel interminable for both of us. I feel like an interrogator, asking questions that are answered, followed by long silences that await my next question. I’d experimented with waiting out the silences and had some instances where ultimately, Nick would continue the conversation, though often his contributions were brief and followed by further silence.
On this particular day, I decided to explore a different approach. After Nick shared he had nothing new to report, I tried something different.
“Well,” I started, “one way we’ve explored what’s going on is to talk about the activities of the week, or what’s been going on ‘outside.’ Could we talk a little about what’s been going on inside? What you’ve been thinking about this past week and what’s been going on inside your head and heart?”
There was a brief pause and I saw Nick exhale. His body settled back into the couch and his head raised slightly. “I’ve felt so sad,” he said quietly.
We began talking about the loneliness he has been feeling. And while we have definitely talked about his loneliness on other occasions, I believe that shifting the start of our session allowed us to enter the loneliness sooner—or maybe it allowed us to be with the loneliness that day when we might not have otherwise.
What stops you?
Everyone comes to therapy to make a change. Still, change is not easy, especially when the ways we’ve learned to navigate the world serve an important purpose—albeit a purpose that may no longer benefit us in all contexts.
When Carrie came to therapy, she wanted to change a pattern of being in unsatisfying relationships with colleagues at work, with friends, and with romantic partners. She shared she often felt inadequate and that she was “almost always” the person taking initiative; that if she didn’t make something happen, she was confident it wouldn’t happen at all.
One session we were talking about a friendship in which Carrie found herself always initiating plans which left her feeling frustrated and unimportant, especially when she learned about plans this particular friend initiated with other people. She agreed that prior to her next session, she would have a conversation with this friend about her feelings.
When she came to her appointment the next week, she began by telling me I was going to be very disappointed in her. “I didn’t talk to Joe,” she apologized. “We talked a few times, but I just couldn’t start the conversation about being disappointed by him.”
I felt the words “Why not?” begin to travel from my brain to my vocal chords and almost leave my lips. And I stopped. Carrie and I have had this conversation before. I’ve asked her “why” or “why not” which has typically resulted in her trying to explain herself to me, and I almost always feel as though there is an implicit judgment in my question.
I remembered a workshop I’d gone to about addressing communication challenges with couples and the presenter had shared a very simple but powerful reframing when the temptation to ask “why?” felt present.
“What do you think stopped you from having that conversation?” I asked her.
I know that question is virtually the same as asking “why” or “why not,” and still each time I’ve asked someone “what stops you?” I am surprised by the amount of information I get that might not have come to me as non-defensively or apologetically if I had asked “why?”
“What stops you,” often removes any kind of implicit or explicit accusation from the question. We’re invited to consider the forces that hold us back from change, in some ways externalizing those forces so that they can be examined more closely without shame. It’s subtle but gentle. And it opened Carrie to sharing her fears of rejection should she ask directly for her needs to be met.
What if you had to guess?
Another session-stopper can be a response of “I don’t know” to one or more of our questions. I remember a recent conversation I had with Robert, a client with a history of childhood physical abuse and years of addiction as an adult. Robert has been sober for 5 years, and in therapy on and off for that same amount of time. Still, he continues to struggle with an awareness of his internal life. Often in sessions, his first response to a gentle probing question is “I don’t know.”
For a while, I took him at face value and didn’t move more deeply into whatever topic we were discussing. Then, one day I asked him a question about how he had responded to co-worker who had treated him poorly. After he responded initially with “I don’t know,” I followed up.
“If you had to guess, what do you think the reasons were?”
He looked perplexed by this question, while at the same time, I could see that he slowed himself down and opened to a bit more introspection.
“Maybe it has to do with not feeling like I deserve better?” he responded almost as a question. “I don’t know if that’s right, but it’s the first thing that came to my head.”
The theme of what Robert “deserves” in his life had been one we’d been exploring for weeks. His “guess” allowed us to explore how internal messages of “deservingness” often stop him from pursuing things that might lead to better health–such as working out, increased financial security—such as saving money, and increased happiness–such as being more direct with his friends and colleagues about what he needs.
Does that happen in here?
When I begin my work with someone new, I try to reserve time during the first or second session to share a little about how I think therapy works. If someone has been in therapy before, I ask about those past experiences. I’ll also try to weave in some conversation about our relationship in therapy and how it evolves over time as an important part of the psychotherapy process.
In a recent conversation with Justine, she was talking about the distance she feels in almost all of her relationships. She talked about her experience of this distance in her family of origin, in her friendships, in work relationships, and in her current relationship with her boyfriend. For the past few months, this theme of distance has arisen on multiple occasions.
Despite working together for several years, I realized Justine and I hadn’t directly discussed our relationship with one another. And I realized that I experienced some distance between us; that our sessions were productive and useful, yet I still felt there was something between us—or perhaps not between us—that limited the extent to which we were connected. On this particular day, I decided to ask Justine if she experienced that same distance she experiences with others in her relationship with me.
“You might remember that when we started therapy I talked about how what we walk about is important, but that how we talk about it and how our relationships develops is also an important part of our work together?”
She nodded that she remembered.
I continued, “So we’ve talked about your experience of distance in so many of your relationships, but we haven’t really talked about whether or not you feel that same distance with me?”
What I often notice when I ask a question that brings relational dynamics into the present moment, is an automatic deepening of the session and in the relationship. With Justine, there was some hesitation after my question, but she haltingly talked about not wanting to get to a place where she depended on me or shared too much with me, only to feel judged or even worse, rejected.
While she said she hadn’t felt judgments by anything I said in sessions, she eventually shared that at times she noticed expressions on my face she thought might reflect an underlying judgment. I wasn’t aware of these moments, but trusted there must have been some subtle shift in my facial expressions and perhaps I was conveying some kind of judgment unknowingly.
I asked if Justine might be open to letting me know when these moments arise. “I’ll try, “ she agreed, “but at those times, it’s sometimes hard for me to say anything.”
We then began to talk about how these moments in sessions might also happen to her in her other relationships, and she immediately saw the parallel. We continued to explore the benefit of engaging in these moments in sessions to see if it helped with feeling closer—less distant. And if we could explore these moments in sessions, I invited her to consider the possibility she might be able to do the same outside of sessions.
How was this session?
While for many of us it is scary to ask for feedback from our clients about how we are doing as therapists or about the process of therapy, research supports that asking for feedback actually improves the therapy experience for most people. But there is another reason I’ll sometimes ask about a particular session or series of sessions.
Michael is someone who self identifies as a “people pleaser.” Growing up gay in a home with two alcoholic parents and a physically abusive uncle who resided in his home, Michael says he was always trying to figure out how to be “the best little boy” in every situation in which he found himself.
Growing up, Michael tried to fly under the radar by never doing anything to make his parents mad, and trying to be as invisible as he could whenever his uncle was home. In school, he followed all his teachers’ directions and was always identified as the model student. He got all A’s in high school and went to a prestigious college, following his father’s footsteps by becoming an electrical engineer.
Despite all his accomplishments, Michael still struggled with self-worth and entered abusive relationships feeling as though it was his responsibility to meet his partners’ needs, without considering needs of his own. He focused on pleasing his partners—in fact so much so—that it was occasionally his focus on them that resulted in relationships ending.
Pleasing others also occurred in our sessions together. He’d often answer questions or make comments looking to me to see if he responded appropriately. We identified how this pattern in our sessions paralleled the patterns he experienced in his relationships with others (e.g. “Does this happen in here?”), and still we struggled with it’s interruption.
There was one session where I tried to do something different as we concluded. I asked Michael: “How was today’s session?” He looked at me quizzically.
“It was great, as usual!” he responded enthusiastically.
I followed with my rationale for asking. I invited us to consider how we might gradually experiment with giving feedback to me in sessions that he might not be willing to give to people outside of sessions—at least not yet. I asked if he’d be willing to let me know at the end of each of our sessions, what he found particularly helpful, but also what he experienced as not as helpful or even unhelpful. The agreement included him identifying things that “worked” for him, as well as things he wished I had done differently. I also understood that his agreement to engage with me in this way might also be a way to “people please,” so I invited us to consider this as well as we proceeded.
Michael quickly understood the purpose of ending our sessions this way, and after several weeks, I no longer had to ask how the session went. He began to let me know more spontaneously when he found something helpful, and although it wasn’t easy for him, he also let me know when I missed something, or when I said something that was either “off,” or was painful to him in some way.
Because we created this experiment, I also believe Michael’s awareness throughout our sessions changed. I found him listening differently and with more discernment. Knowing there was an expectation for him to provide feedback, he seemed to be more open to sharing spontaneously throughout sessions when he found something helpful—and equally important—unhelpful. And as we continue with this, our hope is that he’ll generalize this discernment to his relationships outside the therapy space.
Questions Toward Transforming a Session
Each of the questions I’ve shared has multiple possible follow-up questions and multiple directions we can take once the question is asked and answered. I share these five in hopes that we’ll continue to think of ways we can creatively challenge ourselves when we find ourselves feeling stuck.
While thinking about our theoretical underpinnings can be helpful when we struggle, I’ve found that thinking across theoretical boundaries can offer even greater options. When I allow myself to think more expansively, paradoxically the things I say become more straightforward and less complex.
I also want to be clear that when we experience a stalling or stuckness, that doesn’t mean anything is “wrong,” or that therapy isn’t productive. In fact, I find it is most often those times when we question ourselves or the direction of a particular session, or series of sessions, that we are able to move more deeply into our work, or change directions if necessary.
Of course, a single question or statement doesn’t magically transform our work. But experimenting with asking something in a new way might make a difference. After all, what stops you? If you had to guess? How was this post?
“The power to question is the basis of all human progress.”
All AIDS Anger Apologizing Asking Questions In Sessions Authenticity Beginnings And Endings Being The Expert Boundaries Boundary Crossing Boundary Violations Breaks From Therapy Collaboration Between Therapists Coming Out Compassion Fatigue Contact Between Sessions Continuity Between Sessions Courage Crying Death Depression Disclosure Disclosure And Technology Dogs Email Emotional Support Animals Emotions Empathy Ending Psychotherapy Endings Expectations Experiments Failure Finances Forgiveness Framing Therapy Fraudulence Gifts Goals Grief Happiness Healing Rituals HIV Holding Back Homework Honesty Hope Human Animal Bond Identity Imposter Injuries Interpersonal Neurobiology Intersectionality Long Term Therapy Loss Loving Yourself Memory Metaphors In Psychotherapy Microaggressions Money Multiple Identities Neurophysiology New Information New Normal Normal Not Knowing Pain Physical Contact Positive Emotions Present Moment Priorities Privacy Questions Rage Real Relationships Resentment Resolution Rites Of Passage Rituals Rupture And Repair Sadness Safe Spaces Safety Safety Plan Safety Versus Comfort Secrecy Session Structure Short Term Therapy Silence Stigma And Mental Health Suicide Survival Strategies Themes In Psychotherapy Therapist Client Relationships Touch Trauma Trigger Warnings Values Vicarious Resilience Vicarious Trauma