There is no “talk” therapy without “listen” therapy.

Patients are as likely to say that they want a therapist who talks as they are to say that they want a therapist who listens. Of course, there are patients who can talk but not listen and also patients who can listen but not talk. Or at least there are patients whose predilections are heavily skewed in favor either of talking or of listening. Ideally both therapist and patient are competent in both modes, both able to speak and to listen. This makes a reliable and rich back and forth possible. It supports the ecology of exploratory conversation.

For the first ten years of my career as a psychotherapist I was tormented by a voice in my head that kept ranting at me during sessions that I talked too much. The voice was humiliating without having any particular corrective impact. It simply served to make me miserable as I continued to say what I had to say. The position advocated by this voice was one, I believe, that my mother would have endorsed when I was growing up. I had many questions, many more in my head than I expressed or could have expressed.

But I had ways of expressing that I had doubts, that I was intrigued, that I needed to know more, that explanations presented to me did not seem to hang together, that I had seen moments that had become mysteries. I was in many ways a nuisance and a burden to my mother. She surely thought I asked too much in both senses of the word. But my mother was not one to express her thoughts and feelings in words, especially if they had a negative tinge. This was a tradition in the family in which she was raised. My mother was true to this tradition. But her face was not always true to the tradition, nor were her body postures.

Maybe, in fact, a better way to describe the tradition is to say that what could not be said in words could be represented through the body, through facial expressions, through postures, through the hands and limbs. This involves the speech that is not speech, the “not speech” that preserves a near infinite deniability. I, myself, who have devoted a lifetime to being able say and to hear the realities of human experience and feeling, have had trouble in meetings because I can not keep what I am thinking and feeling off my face. Often when what I think and feel is quite critical, my face has spoken for me before I know it, causing me a lot of trouble.

One way of thinking of the voice in my head that kept accusing me of talking too much in sessions was that it was my mother keeping me company. I had trouble living with it and also trouble living without it, because it went on and on, crossing with me into my forties. I never had a patient tell me I talked too much. I did have patients who told me I didn’t listen well or understand, but virtually all my patients engaged with me, more often under a positive sign, but quite often, too, with trips, some terribly charged, into the negative. They were all expressive.

Much of “talk” therapy does not have to do with talk. It is located in the realm of the non-verbal. It has to do with body-language, with postural attitudes, with facial expression, with the music of what is said as opposed to the semantic content, which is called prosody. It has to do with appearances, quite possibly with scents, consciously and unconsciously detected. It has to do with rhythms of back and forth, with accord and discord in these rhythms, with syncopation. Psychotherapy has a call and response structure that is continually varied, so that a comparison to jazz suggests itself. It does not go too far to advance the notion that psychotherapy is an art form.

“It’s on the days when I come in thinking that I really have nothing to say and don’t know why I’m coming, that I find myself saying the most, discovering what I did not know was there to discover,” proclaimed an anxious and talented woman in her fifties.

I have a theory about this particular phenomenon, one that a number of patients have remarked over the years. My sense is that the conviction of having nothing to say may reflect the fact that all conventional, all habitual subjects and styles of engaging them have been exhausted. It is time for something new. The old has been stalemated, but the novel has not yet been formulated. In a stealthy way, it is preparing to burst out to the surprise of the patient and the therapist Psychotherapy alternates between ruts and riffs. The ruts can be deep, so it is almost impossible to see over them, although a person is very close to a new riff, but without perspective.

Here is what happened with the voice in my head constantly criticizing me during sessions for talking too much. It didn’t take place all at once. Nor did it happen by any conscious resolution on my part. I would have liked to get rid of it for years, but I could not. What took place was that it became clear both in me and to me that I could not practice psychotherapy as anyone but myself. This was not a triumphant realization, but rather one tinged with disappointment, regret and defeat. However much I might have wanted to be a different therapist, a better therapist, a more assured and orthodox therapist, this was beyond me.

If I was the instrument, then I had to play for myself and as myself, rather than to the specifications of others, imaginary and real, current and past. The only way I could find access to discovering the music that was in the instrument was to play for myself and as myself, to follow where the ear pointed, to take seriously what I heard in the winds of therapy. As this process was going on, the voice faded, not all at once, but over some months. It diffused. It left me alone with myself, freer to speak and so also freer to be silent and to listen.

An astute young man arrived at the following paradoxical formulations.

“Sometimes the best way to talk to my girlfriend is to listen to her and sometimes the best way to listen to her is to talk to her.”
Listening, like talking, is an activity. It uses much of the same neural apparatus as talking. What we can call the ecology of listening may be quite different from therapist to therapist. A psychotherapist with a background as a composer described his working state of mind “as a searching singing voice” accompanying the patient and trying to find words that were right. Another psychotherapist with vast experience described bouts of planning and tending his vegetable garden mentally as the patient speaks on. Another therapist reported talking with her patients in her mind. Yet another said that he watched how the patient held herself and noticed himself almost mimicking each little change. This does not even do more than begin to hint at the diversity among therapists in how they deploy and manage themselves as they listen to patients.

Every patient is a new world to discover and explore. A psychotherapist gets little bits of information, a narrative that is often unwittingly disjointed and inconsistent.
Psychological understanding and empathy, the foundational elements of so-called
“talk” therapy, involve a great deal of inference, a connecting of dots that can be very tricky and misleading. Most therapy proceeds by flurries of successive approximation. Listening can be described as tethered imagining and the tether is important.

A good therapist has to be open to course corrections, Such a therapist has to be sensitive to subtle cues that he is not in tune with his patient. He has to have both an ear and an eye for slight clues that he is not constructing the patient’s experience accurately, that his imagining is not properly tethered or, on the other hand, that it is too timid. One way a therapist can misconstrue what his patient says is by thinking he knows, when in fact he is conflating aspects of his own experience with his patient’s. Therapists can end up talking with themselves about themselves when they believe they are engaging with the patient.

Fit between patient a therapist is of enormous importance, probably so much so that it is hardly possible to overestimate how consequential it is. Fit, a word of but one syllable pointing a finger at a vital concept. is not easy to characterize. It has to do with how the therapist’s and the patient’s personalities, predilections, styles of communications, even senses of humor mesh. When there is good fit, usually both patient and therapist are aware of it and enjoy it. When there is bad fit, both patient and therapist suffer with it. Playfulness and inventiveness both suffer under regimes of bad fit, This is important because without a measure of playfulness and inventiveness therapies are likely, perhaps more than likely, to find themselves in barren zones. Good fit involves leaving space for both participants to be themselves.
Good fit means being able to be close but not too close, because too close is suffocating.

Predicting fit, like other acts of matchmaking, is devilishly difficult and does not readily yield to algorithmic thinking. People with similar backgrounds and similar
life experiences may not find it easy to establish the array of channels of communication that the back and forth of therapy requires. Each may construe apparently similar experiences differently and be attached to the particular constructions that are in place. Sometimes people who seem very different on the surface find deeper accord than matchmaking would predict.

An elderly German lady was talking about her war experiences in Nazi Germany when it struck me that she sounded just like my own late father talking about the war. There was the same tone of sorrow and dignified resignation, of abhorring the past and yet having the wisdom to know it was as it was and that it could not be remedied in retrospect. The beginning of the war in Irag with its boastful bombing upset her terribly, for she had known both shocks and what was truly awful. Fireworks bothered her. Her war experiences were right with her, often at the center, as she made her way through her eighties.

In “Psychotherapy and the Single Synapse” in 1977, Erica Kandell reviewed his work with the sea snail, aplysia californica. He showed aplysia could be induced to change its behavior in similar ways as a result of experiences and as a result of direct chemical infusions. He suggested that psychotherapy works by modifying synapases. “Talk” therapy makes a difference by “talking” to a world of synapses.
In this sense it is a “biological” treatment modality. It has to do with the “logos” of a “bios”, how a life is put together and how it comes to make sense.

There are brilliant and highly educated people with doctorates and medical degrees, lawyers, people who are masters of business and prominent in the military who barely are able to match a name to a feeling that they experience. They can use words like virtuosos in their chosen fields, but have not a clue as to how to use words to come to grips with their own or other peoples feelings. This is a realm they do not know how to negotiate with dire implications not only for their families or their love and life partners, but crucially for themselves. “I had no idea that the name of what I was feeling was anger.” The revaluation of language, the extension of its purview into the rich, if not terribly comfortable, domain of feelings is a task that “talk” therapy is well suited to take on. One of “talk” therapy’s jobs is to change the definition and scope of talk. This can be tantamount to inventing a new tongue.

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