How to Engage the Patient
Psychotherapy may rightfully be defined as the art of developing a particular type of conversation with a patient for therapeutic purposes. Each of the topics below describe fundamental aspects of therapeutic activity which generally contribute to the developing of the therapeutic alliance, a crucial component of effective therapy. As the therapist listens and encourages elaboration, he/she will also alternate between an overall acceptance of the patient’s point of view versus challenging the patient to elaborate and potentially revise or amend their description of themselves. Through the highly-individualized process of immersing him/herself in a patient’s emotional experience and inquiring more about it, the therapist has an opportunity to foster curiosity and further reflection in the patient. In turn, in favorable cases, patients respond with greater trust in the therapist’s understanding, empathic connection, and challenging interventions. The mind of the patient can thereby expand to accommodate new meanings and new ways of relating.
Listening attentively is experienced by most patients as comforting, especially with careful attention to what feelings the therapist may discern with which the patient is struggling (and may not be aware of, or may be too embarrassed to reveal). The therapist is there for the patient, listening and witnessing aspects of the patient’s emotional life that may rarely be disclosed to anyone else, and offering him/herself this way often evokes strong feelings in the patient. Leo Stone wrote a slim book that describes some of the early origins of the feelings evoked, called The Psychoanalytic Situation (1973). In an influential paper titled “Primary Maternal Preoccupation” (1956), Donald Winnicott also discussed how early experiences with a parent holding her infant child in mind affect the child’s ability to manage his/her emotions and understand the world. There is often a therapeutic impact from our focusing neutral curiosity and attention on the patient, or bearing witness to tremendous suffering and helplessness while still remaining capable of thought and reflection.
It is equally important to monitor whatever feelings the therapist is having as he/she is listening, because so much of our capacities to be aware of others occur outside of our conscious awareness. The metaphor used by an influential writer about how we respond in life situations (Jonathan Haidt, in The Righteous Mind, 2013) is that our conscious mind is like the rider atop an elephant. We are fond of the illusion that we determine where the elephant goes!
Encouraging elaboration is the first tool described and illustrated in our PRC Psychotherapy Manual [see here]. It is what we do most in the beginning, but often continues throughout therapy. It is a straightforward means to add to what one knows of the patient’s thoughts and feelings, and, if done tactfully, it can provide a safe, unobtrusive environment for the patient to explore new emotional territory or reflect on him/herself and others. We encourage elaboration based upon what we discern as described in the previous paragraph, particularly when the patient seems to pause or veer away from a deeper elaboration of a topic (see Paniagua, 1991).
Closely related to encouraging elaboration is allowing silences to occur in the conversation, when the therapist has the impression that the patient may very well continue on their own. It is interesting how often patients will only have a dream come to mind in just such a silence [for example, click here to see this unfolding in an early session of psychoanalysis].
In the first few meetings, patient and psychotherapist typically discuss how or why the patient’s emotional life has led them to consult a psychotherapist at this particular time. Ideally, patient and psychotherapist become collaborators in describing the nature of the patient’s problems and how best to recover from them. Moreover, in the elaboration of this conversation, patient and psychotherapist can revise or clarify any disagreements in how they each view these difficulties.
As a therapist listens to the patient’s emotional troubles, it stands to reason that the patient will struggle with how to conceive of his/her difficulties. In these moments, the therapist can tactfully highlight the particular manner by which the patient is thinking about his/her own feelings. Here are relevant examples from the PRC manual of clinical situations that occur early on in establishing a therapeutic conversation between therapist and patient:
- Sometimes, a patient has not yet identified the emotional problem.
- At times, a patient finds it difficult to think about how his/her feelings relate to his/her difficulties.
When patient and psychotherapist more or less agree on how to understand the problem and how to treat it, psychotherapy has the best outcome. Click here to understand more about the development of this therapeutic alliance.