Sep 23, 2022
Have you ever wondered what is the most important question in psychotherapy? No spoilers here just check out the conversation!
Transcript:
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Mike now
here's psych with Mike welcome into the site with Mike Library this
is Dr Michael Mahon and I am here with Mr Brett Newcombe hello the
uh psych with
Mike Library window is open that's a new way to start yeah I mean
I
guess people could walk by and ask for ice cream but you can either
look in the window or jump out yeah whichever you
want whichever you feel is how do you feel about that I I feel
really good about it I'm the point is that it's it's
very nice outside and after the summer that we've had in St Louis I
am really
glad that the weather is milder it's been a beautiful week yeah so
uh we
don't even need to get into global warming because that's because
that's a crazy kind of divisive
topic but uh it was really hot this summer yeah and it's hard still
hot in
major sections of the country and the world yeah it and and when
you look at what's been going on in India uh in a
third of the country underwater that's I can't even conceive of
what that would
be like yeah so anyway so I'm glad that we're going to get some
milder temperatures I am uh a feared that the
Farmer's Almanac is predicting a tremendous amount of snow in the
St
Louis area for this winter so we'll see how how that works out
yeah
so how are you today I'm doing well you don't want to talk about
anything we were talking about before the before we
started this do you no okay because there's been lots of stuff
going
on there is always always interesting in doing therapy people come
in and it's
like there's always going on lots of stuff going on yeah so
um when you were doing therapy I think that
uh probably each individual person doing
therapy has their own style obviously yes yeah
and probably most people would have a different answer to this
question but
what was your favorite or most important question in therapy
how are you this week and what would you like to talk about so
what's hot what's Burning uh in your
mind your Mentor slash hero um
blanking on his name yellow yeah Irving yallum uh uh his intro
question was what
hails so in all of his books that's how he would start out all of
his therapy
sessions what what else what else yeah um which I always found
pedantic and
beatnik like yeah but uh but yeah I mean he always wore the black
turtleneck and
I don't know that he wore what is the the cap that the French wear
you know we all have our affectations in
our presentation exactly I used to tell people would call and say
yeah I'm thinking about coming to you I've been referred to you
uh
How will I know and I would say you know it is incredibly important
that there is
a sense of safety and connectivity for this to work so come see me
come see me
once or twice and don't pay me but if you come back the third time
pay me for
three sessions and every session after that but I really feel like
if you spend some time with me you'll get a sense of
whether I'm going to be a fit for you whether I'm going to be able
to hear you and what you need to talk about right uh
well you're Jumping the Shark because we we definitely want to talk
about what is a good therapist yeah but so when we're
talking specifically about the questions do you believe
that the therapists questions
are important for directing the course of therapy or do you believe
that the
therapist is more of a passenger a passive so I taught in a
counseling
program for 35 years and I would constantly say to my students who
wanted
to become therapists and in addition to having my private practice
for all those years but I would say to my students you
cannot do formula therapy you can't have a formula that you follow
for every client that comes in whether that's a
label that you apply to yourself I'm a cognitive behavioral
therapist or I'm a union therapist or whatever
uh because people don't know that and don't understand that they
don't know what it represents what it means what
you need to say is I am invested in paying attention to you
and
hearing what it is that you need to have heard and then proving to
you that I've heard you
accurately and correctly both both in terms of what you say and in
terms of what you're feeling when you say it so
we will explore that reality for you and if that's a fit then be
spending time here will help you
make progress with whatever concerns that you have I think you'll
get better but if if I'm not the fit then go
somewhere else don't say well therapy doesn't work I went to this
guy he was a bozo there are bozos out there but if
you feel comfortable with me and we can spend time together I
believe that we
can make progress in terms of what hurts you or what you need to
address in your life to make your life better but just
as far as the the who's driving the train yeah do you
believe that the therapist no drives a trainer do you believe the
client right yeah yeah and I'm not bringing it to the
table you are my job is to ask you what are you bringing to the
table right what what's going on and then do reflective
uh listening to say well this week you said you were bringing to
the table an
argument that you had with your boss but we spent 45 minutes here
talking about other things and I'm wondering how to
understand that if that's what was hot for you when you got here we
haven't even approached it and we've nibbled at
a time or two but we keep going down these other paths about this
or that or the other so I'm wondering how to
understand it I'm wondering how you understand that so the most
important question is the question that helps to
direct the client towards themselves better self-awareness right
and they'll
come out in and they'll throw out red herrings so that they feel
like we spent a
productive hour and you feel like we spend a productive hour
because we try to solve this puzzle it's a very seductive thing
they'll ask for advice
what do you think in your experience how does this work uh why and
they always
want to talk about somebody else why is my mother doing this why is
my mother this way and the
to my thinking the point of being there isn't to figure out why
your mothers are your boss or your next door right why
you are enduring this or tolerating this or making these
choices
and we talk about emotional economics you know you're frustrated
you're upset you're angry you're hurt you're sad
whatever how's that costing you what's that costing you in terms of
physiological
issues are you having chest pains or you're having anxiety attacks
do you have headaches you're having trouble sleeping you've got TMJ
problems what's
going on with the way that you handle this issue and then in terms
of your emotional
status are you grouchy are you angry are you sad are you numb uh
are you
frustrated I so many times having conversation with parents and
they would come in and talk about
and I said to my child how many times do I have to tell you and I'd
start laughing at them and I'd say you know if
you've heard yourself say that more than twice you've said it too
many times yeah so let's let's talk about Plan B if just
telling them you need to do your homework and they're not or you
need to wash the dishes clear the table whatever
it is you've asked them to do and they haven't done it what's next
so I think that
many therapists we've both been involved in programs teaching in
programs that
educate the next generation of therapists and
from the therapist that I know and the students that I've
taught
it feels like to me and I could be wrong so I'll ask you what your
reflection on
this is that a lot of their a lot of people who are going to school
to be therapists want the formula they want
some kind of reassurance that you you give me the formula the
questions to ask
I'll ask the questions and then I've discharged my duty that'll
make me feel like that I'm doing what is right and
you know the insurance companies uh support that thought absolutely
because they want to pay certain amounts for
certain things and they claim that the data collection that they
have justifies the approval or the expense or the money
investment at a time uh but I I keep coming back to you know
formula therapy
and agenda therapy I think both are not therapy and I also would
say 35 years of
teaching and counseling program at two different universities um a
lot of people who come to try to
become therapists are so seriously wounded that they're going to
hamstring
themselves right by their issues right uh and their agendas you
know you can't be
proselytizing for your agenda uh whatever it may be
whatever you're really promoting is the right answer that's not
doing therapy yeah and when we were in grad school and
and you did Role Play Everybody did role play we hate role play
okay but but everybody does it and and I did it
poorly well but we did I mean we had actual groups in in your group
therapy
class we did and but I said we're not role playing what what
whether you call that role playing or not but but you
know I used to say all the time the next time that somebody says to
me the reason I got into this because everybody asks
oh why'd you get into this program you know that's the first that's
the Icebreaker for every class that you go to so the next time
somebody says oh you
know I have a dysfunctional family I wanted to understand it but
I'm gonna punch him in the throat okay you know no which is a very
clinical reaction well
you're in a Therapy Program well I was in there yeah it wasn't like
I was doing therapy uh and and no doctor said oh I
went to medical school because I knew my appendix was going to go
bad at some point and I wanted to be able to take it out I know how
to deal with it yeah so
you know that's a bad bad reason to go I went to to school to be a
therapist
because I couldn't pass calculus is what they're saying it's the
answer that they
give but they're not deep enough there's something under that for
what drives you I want to help people I'm on a mission
from God I believe in doing good in the world whatever it might be
or I think uh
I know I was abused as a child and I know how damaging abuse is and
so I want
to protect all children from being abused but that's a reason to be
in therapy not a reason to do therapy
exactly yeah yeah I agree with that 100 yeah and and so you know
that doesn't
mean that you shouldn't be doing therapy but you shouldn't be if
you're using your own dysfunctional past as the
motivation for why you're doing therapy I think you're going to get
caught up in that agenda profile
well that is uh one of the reasons why for a number of years I
refuse to see
active acting out alcoholics because I came from a violent
alcoholic family and
I had so many of my own personal and that's called counter okay
don't feed me lines like
that you want to say it say it that's called counter transfer yes I
know okay uh so you try not to do that you don't
want to do that as a therapist yeah it disrupts the connection the
dynamic the
orientation of the session they're paying you to listen to you and
that's
not what you're supposed to be doing right and I didn't work with
and still don't if I can help it work with sexual
abusers and people say oh well you should you know work with
everybody or what you know I didn't feel like I don't
work with borderlines I don't feel like that that is my clinical
expertise yeah I don't have the expertise or you say
those those issues are too close to me I can't I can't see clearly
I can't hear but it is the therapist's responsibility
to know what you know the Old Dirty Harry line a man's got to know
his limitations yeah you got to know what
your limitations are and you have to practice within those
limitations I don't I don't not see borderlines
because I don't think I'm clinically able I don't see borderlines
because I find that push your buttons yeah I get
seduced by the borderline presentation seduce or distracted
yeah because they'll say here chase this rabbit or here chase this
rabbit and every once in a while you're so focused
on a particular kind of rabbit that you're like oh I'm after that
and then again they're steering the
direction of the conversation to reinforce their own
circumstances
right and justify them but it isn't to me it isn't a weakness
for a therapist to say this isn't my area of special I agree it's a
string I
would agree with that yeah now that at the same time I also don't
think that
new therapists should say I'm exclusively an alcohol substance
abuse
counselor no because I think that makes them feel safe because they
are trained or they know the right answer they know
the theories that they're taught in school or that they've been
taught in school slash AAA uh and so they notice
that you know one day at a time uh let go and let God and never say
those
things automatically in conversations uh they can laugh about
things like 13
stepping uh on a 12-step program the hell does that mean what's
going on there uh so they know the inside Works
they feel safer but individuals are never limited to
whatever the presenting pathology is and so if you say oh I can
only work with
substance abuse individuals then but but those people have other
issues this
diamond only has one facet right yeah right so I'm my you
know
encouragement my advice to people who are doing therapy or newly
thinking about going into therapy is you got to
find that balance don't try and practice outside your expertise but
also don't limit yourself to one specific pathology
so then that brings me to therapists need to either uh okay
hold
on to that question and or that thought and we'll pick that up
after our break I might forget
hey Brett if you were going to tell somebody to check out something
on the
Internet to help them with their mental health what would you tell
them I tell them to listen to sex with Mike why
would you tell him that because it's probably one of the most
easily listenable experiences you can have that
would give you information that's useful for a whole spectrum of
concerns that
people have I agree and I have actually been told that by at least
a dozen
people several of whom were not married to me and some of them
didn't even know
me that's amazing that is amazing it's when when we get that kind
of feedback
from people it is so incredibly humbling and overwhelming for me it
is for both
of us so we really appreciate it and as always if it's Friday it's
Mike
[Music] all right we're back did you forget I
don't know like it just comes and goes so quickly now what I was
going to say is and again the thing that I used to
say to people all the time never practice alone if you practice
alone it's too easy to get distorted and
caught up in rhythms that uh if you had supervision or and even
collegial not
hierarchical supervisor yeah working for a boss who can tell you
yes or no but uh
collegial supervision and most therapists I know do have those kind
of groups that they meet with and they talk
to and you say I have this client that's really pushing all my
buttons all right this client that's presenting this this
singing and it makes me so sad or I'm so concerned about them that
I am losing my objectivity uh or I have issues with
keeping boundaries for this particular kind of experience and other
therapists
and clinicians can say well I have that so you're not crazy you're
not not rare and this is a way that I work with it
how do you work with it and we can have those conversations to help
keep you professional and focused keep both you
and your clients safe from contamination and it's really an
important issue so do
you think that therapy so if I'm doing therapy and I'm in therapy
does that
serve that was the same question that we had for 35 years yeah does
every therapist need to be in therapy and I
would not make that as a legalistic qualifier I would say it's
probably a good idea but I would say you need to
have collegial or hierarchical supervision over your cases so okay
so
uh I want to I want to drill down on that a little bit because you
know I think that you should be in therapy if
you're doing therapy because I think it keeps clean the
transference counter transference projective identification
but I'm not sure that it serves the same function as collegial
supervision
I'm not sure anymore okay so if I'm going to therapy and I'm
talking about my counter transference that may help me
be cleaner in being able to identify and deal with the counter
transference but
may not necessarily help me in the area of boundaries so I I went
to therapy and
one of the challenges that I understood going in that I discussed
with my
therapist going in is having done therapy as a provider for
35
years I feel like I'm at risk to play therapy games and
head games if you helped me find a live nerve that might
be painful or frightening for me instead of going with that
and
experiencing whatever that is I'm capable of distracting you with
something else
and I don't want to do that so we both need to help watch me and so
that I can
avoid that because as any other human being when I
get to the most raw places inside me that I'm trying to get out and
put on
display for the therapist to say how do you understand this uh what
does
that make you think about me am I accurately pulling it out of me
or am I
still guarding it and guiding it and lying about it uh it's a scary
proposition so I will avoid
it and people do that in therapy all the time that's why the
presenting problem that they first come to you with is almost never
the real issue in their
lives it is an issue it's a real issue but it's never the
issue
so you have to spend enough time making them safe solving problems
not solving
for them but with them so they can build the trust in the process
and in you and
in themselves to be able to look deeper yeah so do you agree though
that therapy
is not the same as collegial supervision yes I do and and so if
you're going to have
one you should definitely have collegial supervision you can
certainly have both
yeah absolutely okay so that's what we're saying to people is that
you got to at
least have the collegial supervision yeah and and it doesn't have
to be formalized like you and I have had a
relationship since before I was ever a therapist so for as long as
I've been a
a practicing therapist you and I have had that relationship
okay not not that I'm aware of okay uh but I mean you you have to
you're trying
to blame all that on me I know where this is you have to take that
responsibility for yourself but uh so
sometimes that was more formalized when we were in a group practice
together and sometimes it's been less formalized I
don't think that it needs to be formal I think that you have to oh
you're gonna do it over coffee you just need to get
it on a regular basis right and and all of the knowledgeable or
trained or licensed participants need to bring
something to the table mm-hmm well what have you been seeing
because another thing that happens is really that's such
a great point though is themes or threads go through a community
and it's
like wildfire contagion so you get a half a dozen new clients and
they're all
dealing with depression and you go to collegial therapy and
everybody else is saying my god I've had so many people
coming in with depression in the last couple weeks which it's in
the water uh just to by way of an example and it's
helpful to get that feedback and it's helpful to get everybody
else's perspective on how are you dealing with
that how are you approaching that I remember having a meeting I
don't know if you'll remember this but when we were
in a group practice right and the gal who was the director actually
took you
and I into a room because she wanted to have these Grand uh
clinical meetings
yeah and so we would have these meetings and say okay somebody
needs to present a
case and crickets crickets crickets and she took you and I into a
room and said you guys are the seniors here everybody
looks up to you and you guys need to present because that'll make
everybody
else feel safe and and I don't know that either one of us
well
I wasn't opposed to the presenting I was opposed to the way it was
presented to
me yeah because I quasi staged yeah well I mean it was like you you
like we were
getting dressed down because nobody else would participate but I
will say that we started doing those things regularly and
other people did start to open up and some of those meetings were
really
really good and beneficial I think not just for the individual who
was presenting the information but for
everybody the community that was in that room yeah exactly yeah I
mean that can be so powerful absolutely and
encouraging you know you get reinforced that you're not saying it
wrong you're not seeing it
incorrectly you're handling it well according to the committee
opinion and
that's positive affirmation and we all appreciate positive
affirmation so let's Circle back to what the original topic
was which was the most important question in therapy and this idea
of the
difference between an open-ended and a closed-ended question what's
the difference between so a couple things
occurred to me one is when clients becoming new clients would come
in sometime in the first session or two one
of the questions that I would ask is if our work together is
productive and
positive and on target how will your life be different if what we
do together is beneficial for you
what will be different what are you looking for do you know do you
think do you feel
your relationship your mother be improved your relationship with
your mother will be severed you'll get out of
bankruptcy who knows what it's going to be but you have a concept
of that so
then they start talking and what that does is sets for the
therapist if not the client what the goals of therapy are so a lot
of times people talk about oh you had to have
goals and you got around but it doesn't have to be that formalized
that question right there helps me as the therapist
understand that may be you know what the client says in in response
to that
question might be what they're looking for but it might not I mean
it might just be what they're talking about
because they haven't they don't feel safe enough to really peel
back the layers of the onion yeah yeah right
right but but those are ways of establishing goals in therapy so if
you're a new therapist and you're asking
that question what you're getting the information you're getting
back helps you to understand where the client might
want to go in the therapy session and so as you listen to a
client
one I mean there are different labels and skill techniques that
this discusses
but you you listen to the phraseology and the verbalisms that they
use
and that helps you learn how they think and how they
experience
neuro-linguistic programming is a term and you listen to what they
say and you
you listen between the lines you hear more and you're watching on
verbals and you learn when to say wait a minute I'm
I'm picking something up here it's not in focus it could be me
that's out of focus but
it could be you and so give me some feedback you're not getting
this
accurately are you struggling with this did you just twitch did you
just have a flash of a distraction or a thought and
you that's called uh I think it was a call it just went blank
uh silent uh okay uh I'm I lost it okay well but so a
closed-ending question is in question that can be answered with a
single word so if I say did you go to the store
yesterday yes sir you can say yes or no yeah on which store right
but an open-ended question it requires more of
an elucidation so if I say to you you know what it was your fun
this childhood
memory and you say Saturday well obviously it requires more input
than
that so in therapy we're trying to ask open-ended questions because
the answer
that is provided by the client could give us additional information
that's
more than Justice it gives you a directional approach but but there
is one open-ended question that you never
ever ever ever ever ask you like me everybody always does no why oh
yeah
yeah yeah I lost my temper and punched my questioning us why would
you do that
why do you lose your temper I don't know how they're going to
answer that yeah so
you don't say why so you don't ask open-ended questions that put
the client
in a down position no you don't do that
you ask them exploratory questions yeah how do you understand that
how did you
experience what did it feel like yeah uh well and then so now
you're going back because I asked you originally what was
your most important question in therapy but I never answered that
for me it is
how do you feel about that because emotional regulation is so much
a central part of how I see human
pathology that that for me is the most important question how do
you feel about that I think most people answer that
with how they think about that and and I point that out yeah
because you got to get to the field right and so one of the
first things that I do is to train clients that if I say how do you
feel
about that you have to answer glad mad sad or scared you can't
because if you
don't use an affective AFF ECT affective word which is the
psychological word for
emotion then you're telling me how you think so if I ask you how do
you feel about that and you say I felt
disrespected well you can't feel disrespected that's not a Feeling
you can think that you were disrespected and
let's assume for the sake of argument that you did think that you
were disrespected how do you feel about that
well I felt angry okay now we're talking about affect and so I
train people to
use that affective language so that and as they start to go through
therapy they
get reinforced with that hopefully they'll take that outside of
therapy so when they start talking to other people in their lives
they'll actually start
having those affective conversations rather than just talking about
how they think because you're absolutely right 99
of us 99 of the time when we are asked how we feel we tell people
what we think
well and classically Men answer I don't know yeah how do you feel
about that I don't know yeah I I and I'll end with
this little anecdote but uh when I was working at the hospital
there was another guy that worked there and
I'm not going to say his name but to be honest with you I don't
remember what his name was this was a long long time ago uh and he
would do groups and his
response to everything that anybody said in group was anger about
that anger
about that yeah anger about that and I said to him one day you know
there are more emotions than
just anger I I you know I how how much it would have just been so
easy to say oh so how did you feel about that how
did that make you feel but he would just always say anger about
that and yes maybe the person was angry but maybe
they were hurt and they were using anger as a cover-up and that's
one of the things and that's what I want to end on
is that most people in our society at least and I think in
the
world in general use anger as a way to cover up hurt and a part of
therapy is
to go deep enough to help people recognize the way that they might
be
covering their emotions with other emotions camouflage yeah yeah
accurate
reflective listening yes what I couldn't remember so important yeah
essential the
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