The Most Important Question in Therapy

Have you ever wondered what is the most important question in psychotherapy? No spoilers here just check out the conversation!   https://www.psychologytoday.com/us/blog/insight-therapy/202209/the-most-important-question-in-therapy   Transcript: you're listening to psych with Mike for more episodes or to connect with the show with comments ideas or to be a 0:07 guest go to www.psychwithmike.com follow the show on 0:12 Twitter at psych with Mike or like the Facebook page at psych with Mike now 0:18 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 0:26 Mike Library window is open that's a new way to start yeah I mean I 0:32 guess people could walk by and ask for ice cream but you can either look in the window or jump out yeah whichever you 0:37 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 0:45 very nice outside and after the summer that we've had in St Louis I am really 0:53 glad that the weather is milder it's been a beautiful week yeah so uh we 1:01 don't even need to get into global warming because that's because that's a crazy kind of divisive 1:07 topic but uh it was really hot this summer yeah and it's hard still hot in 1:14 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 1:21 third of the country underwater that's I can't even conceive of what that would 1:27 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 1:37 Farmer's Almanac is predicting a tremendous amount of snow in the St 1:44 Louis area for this winter so we'll see how how that works out yeah 1:50 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 1:56 started this do you no okay because there's been lots of stuff going 2:03 on there is always always interesting in doing therapy people come in and it's 2:08 like there's always going on lots of stuff going on yeah so 2:14 um when you were doing therapy I think that 2:19 uh probably each individual person doing 2:26 therapy has their own style obviously yes yeah 2:34 and probably most people would have a different answer to this question but 2:39 what was your favorite or most important question in therapy 2:52 how are you this week and what would you like to talk about so what's hot what's Burning uh in your 3:00 mind your Mentor slash hero um 3:05 blanking on his name yellow yeah Irving yallum uh uh his intro question was what 3:14 hails so in all of his books that's how he would start out all of his therapy 3:20 sessions what what else what else yeah um which I always found pedantic and 3:28 beatnik like yeah but uh but yeah I mean he always wore the black turtleneck and 3:34 I don't know that he wore what is the the cap that the French wear you know we all have our affectations in 3:42 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 3:49 How will I know and I would say you know it is incredibly important that there is 3:55 a sense of safety and connectivity for this to work so come see me come see me 4:00 once or twice and don't pay me but if you come back the third time pay me for 4:06 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 4:13 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 4:21 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 4:29 talking specifically about the questions do you believe 4:34 that the therapists questions 4:41 are important for directing the course of therapy or do you believe that the 4:46 therapist is more of a passenger a passive so I taught in a counseling 4:52 program for 35 years and I would constantly say to my students who wanted 4:58 to become therapists and in addition to having my private practice for all those years but I would say to my students you 5:05 cannot do formula therapy you can't have a formula that you follow for every client that comes in whether that's a 5:13 label that you apply to yourself I'm a cognitive behavioral therapist or I'm a union therapist or whatever 5:21 uh because people don't know that and don't understand that they don't know what it represents what it means what 5:28 you need to say is I am invested in paying attention to you and 5:35 hearing what it is that you need to have heard and then proving to you that I've heard you 5:41 accurately and correctly both both in terms of what you say and in terms of what you're feeling when you say it so 5:47 we will explore that reality for you and if that's a fit then be spending time here will help you 5:54 make progress with whatever concerns that you have I think you'll get better but if if I'm not the fit then go 6:01 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 6:07 you feel comfortable with me and we can spend time together I believe that we 6:14 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 6:22 as far as the the who's driving the train yeah do you 6:27 believe that the therapist no drives a trainer do you believe the client right yeah yeah and I'm not bringing it to the 6:35 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 6:41 uh listening to say well this week you said you were bringing to the table an 6:47 argument that you had with your boss but we spent 45 minutes here talking about other things and I'm wondering how to 6:53 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 6:59 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 7:05 understand it I'm wondering how you understand that so the most important question is the question that helps to 7:12 direct the client towards themselves better self-awareness right and they'll 7:19 come out in and they'll throw out red herrings so that they feel like we spent a 7:25 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 7:32 what do you think in your experience how does this work uh why and they always 7:37 want to talk about somebody else why is my mother doing this why is my mother this way and the 7:44 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 7:50 you are enduring this or tolerating this or making these choices 7:56 and we talk about emotional economics you know you're frustrated you're upset you're angry you're hurt you're sad 8:01 whatever how's that costing you what's that costing you in terms of physiological 8:08 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 8:16 going on with the way that you handle this issue and then in terms of your emotional 8:22 status are you grouchy are you angry are you sad are you numb uh are you 8:28 frustrated I so many times having conversation with parents and they would come in and talk about 8:34 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 8:40 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 8:48 telling them you need to do your homework and they're not or you need to wash the dishes clear the table whatever 8:54 it is you've asked them to do and they haven't done it what's next so I think that 9:01 many therapists we've both been involved in programs teaching in programs that 9:07 educate the next generation of therapists and 9:12 from the therapist that I know and the students that I've taught 9:18 it feels like to me and I could be wrong so I'll ask you what your reflection on 9:23 this is that a lot of their a lot of people who are going to school to be therapists want the formula they want 9:31 some kind of reassurance that you you give me the formula the questions to ask 9:37 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 9:45 you know the insurance companies uh support that thought absolutely because they want to pay certain amounts for 9:51 certain things and they claim that the data collection that they have justifies the approval or the expense or the money 9:57 investment at a time uh but I I keep coming back to you know formula therapy 10:02 and agenda therapy I think both are not therapy and I also would say 35 years of 10:11 teaching and counseling program at two different universities um a lot of people who come to try to 10:18 become therapists are so seriously wounded that they're going to hamstring 10:24 themselves right by their issues right uh and their agendas you know you can't be 10:31 proselytizing for your agenda uh whatever it may be 10:36 whatever you're really promoting is the right answer that's not doing therapy yeah and when we were in grad school and 10:44 and you did Role Play Everybody did role play we hate role play okay but but everybody does it and and I did it 10:51 poorly well but we did I mean we had actual groups in in your group therapy 10:57 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 11:05 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 11:11 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 11:18 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 11:25 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 11:32 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 11:39 you know that's a bad bad reason to go I went to to school to be a therapist 11:44 because I couldn't pass calculus is what they're saying it's the answer that they 11:49 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 11:55 from God I believe in doing good in the world whatever it might be or I think uh 12:00 I know I was abused as a child and I know how damaging abuse is and so I want 12:06 to protect all children from being abused but that's a reason to be in therapy not a reason to do therapy 12:12 exactly yeah yeah I agree with that 100 yeah and and so you know that doesn't 12:18 mean that you shouldn't be doing therapy but you shouldn't be if you're using your own dysfunctional past as the 12:25 motivation for why you're doing therapy I think you're going to get caught up in that agenda profile 12:32 well that is uh one of the reasons why for a number of years I refuse to see 12:38 active acting out alcoholics because I came from a violent alcoholic family and 12:44 I had so many of my own personal and that's called counter okay don't feed me lines like 12:50 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 12:58 want to do that as a therapist yeah it disrupts the connection the dynamic the 13:05 orientation of the session they're paying you to listen to you and that's 13:11 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 13:18 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 13:26 work with borderlines I don't feel like that that is my clinical expertise yeah I don't have the expertise or you say 13:32 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 13:40 to know what you know the Old Dirty Harry line a man's got to know his limitations yeah you got to know what 13:45 your limitations are and you have to practice within those limitations I don't I don't not see borderlines 13:53 because I don't think I'm clinically able I don't see borderlines because I find that push your buttons yeah I get 13:59 seduced by the borderline presentation seduce or distracted 14:04 yeah because they'll say here chase this rabbit or here chase this rabbit and every once in a while you're so focused 14:11 on a particular kind of rabbit that you're like oh I'm after that and then again they're steering the 14:17 direction of the conversation to reinforce their own circumstances 14:23 right and justify them but it isn't to me it isn't a weakness 14:28 for a therapist to say this isn't my area of special I agree it's a string I 14:34 would agree with that yeah now that at the same time I also don't think that 14:39 new therapists should say I'm exclusively an alcohol substance abuse 14:46 counselor no because I think that makes them feel safe because they are trained or they know the right answer they know 14:53 the theories that they're taught in school or that they've been taught in school slash AAA uh and so they notice 15:00 that you know one day at a time uh let go and let God and never say those 15:05 things automatically in conversations uh they can laugh about things like 13 15:12 stepping uh on a 12-step program the hell does that mean what's going on there uh so they know the inside Works 15:19 they feel safer but individuals are never limited to 15:25 whatever the presenting pathology is and so if you say oh I can only work with 15:31 substance abuse individuals then but but those people have other issues this 15:36 diamond only has one facet right yeah right so I'm my you know 15:42 encouragement my advice to people who are doing therapy or newly thinking about going into therapy is you got to 15:49 find that balance don't try and practice outside your expertise but also don't limit yourself to one specific pathology 15:58 so then that brings me to therapists need to either uh okay hold 16:05 on to that question and or that thought and we'll pick that up after our break I might forget 16:12 hey Brett if you were going to tell somebody to check out something on the 16:19 Internet to help them with their mental health what would you tell them I tell them to listen to sex with Mike why 16:25 would you tell him that because it's probably one of the most easily listenable experiences you can have that 16:32 would give you information that's useful for a whole spectrum of concerns that 16:38 people have I agree and I have actually been told that by at least a dozen 16:44 people several of whom were not married to me and some of them didn't even know 16:50 me that's amazing that is amazing it's when when we get that kind of feedback 16:56 from people it is so incredibly humbling and overwhelming for me it is for both 17:03 of us so we really appreciate it and as always if it's Friday it's Mike 17:09 [Music] all right we're back did you forget I 17:15 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 17:21 say to people all the time never practice alone if you practice alone it's too easy to get distorted and 17:29 caught up in rhythms that uh if you had supervision or and even collegial not 17:36 hierarchical supervisor yeah working for a boss who can tell you yes or no but uh 17:42 collegial supervision and most therapists I know do have those kind of groups that they meet with and they talk 17:47 to and you say I have this client that's really pushing all my buttons all right this client that's presenting this this 17:53 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 18:02 keeping boundaries for this particular kind of experience and other therapists 18:08 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 18:15 how do you work with it and we can have those conversations to help keep you professional and focused keep both you 18:22 and your clients safe from contamination and it's really an important issue so do 18:27 you think that therapy so if I'm doing therapy and I'm in therapy does that 18:33 serve that was the same question that we had for 35 years yeah does every therapist need to be in therapy and I 18:40 would not make that as a legalistic qualifier I would say it's probably a good idea but I would say you need to 18:47 have collegial or hierarchical supervision over your cases so okay so 18:53 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 18:59 you're doing therapy because I think it keeps clean the transference counter transference projective identification 19:05 but I'm not sure that it serves the same function as collegial supervision 19:12 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 19:20 be cleaner in being able to identify and deal with the counter transference but 19:25 may not necessarily help me in the area of boundaries so I I went to therapy and 19:34 one of the challenges that I understood going in that I discussed with my 19:39 therapist going in is having done therapy as a provider for 35 19:45 years I feel like I'm at risk to play therapy games and 19:51 head games if you helped me find a live nerve that might 19:56 be painful or frightening for me instead of going with that and 20:02 experiencing whatever that is I'm capable of distracting you with something else 20:07 and I don't want to do that so we both need to help watch me and so that I can 20:15 avoid that because as any other human being when I 20:20 get to the most raw places inside me that I'm trying to get out and put on 20:25 display for the therapist to say how do you understand this uh what does 20:31 that make you think about me am I accurately pulling it out of me or am I 20:38 still guarding it and guiding it and lying about it uh it's a scary proposition so I will avoid 20:44 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 20:51 lives it is an issue it's a real issue but it's never the issue 20:57 so you have to spend enough time making them safe solving problems not solving 21:02 for them but with them so they can build the trust in the process and in you and 21:10 in themselves to be able to look deeper yeah so do you agree though that therapy 21:16 is not the same as collegial supervision yes I do and and so if you're going to have 21:21 one you should definitely have collegial supervision you can certainly have both 21:27 yeah absolutely okay so that's what we're saying to people is that you got to at 21:32 least have the collegial supervision yeah and and it doesn't have to be formalized like you and I have had a 21:38 relationship since before I was ever a therapist so for as long as I've been a 21:44 a practicing therapist you and I have had that relationship 21:51 okay not not that I'm aware of okay uh but I mean you you have to you're trying 21:57 to blame all that on me I know where this is you have to take that responsibility for yourself but uh so 22:02 sometimes that was more formalized when we were in a group practice together and sometimes it's been less formalized I 22:07 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 22:14 it on a regular basis right and and all of the knowledgeable or trained or licensed participants need to bring 22:21 something to the table mm-hmm well what have you been seeing because another thing that happens is really that's such 22:27 a great point though is themes or threads go through a community and it's 22:32 like wildfire contagion so you get a half a dozen new clients and they're all 22:39 dealing with depression and you go to collegial therapy and everybody else is saying my god I've had so many people 22:44 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 22:51 helpful to get that feedback and it's helpful to get everybody else's perspective on how are you dealing with 22:58 that how are you approaching that I remember having a meeting I don't know if you'll remember this but when we were 23:03 in a group practice right and the gal who was the director actually took you 23:09 and I into a room because she wanted to have these Grand uh clinical meetings 23:16 yeah and so we would have these meetings and say okay somebody needs to present a 23:21 case and crickets crickets crickets and she took you and I into a room and said you guys are the seniors here everybody 23:29 looks up to you and you guys need to present because that'll make everybody 23:34 else feel safe and and I don't know that either one of us well 23:39 I wasn't opposed to the presenting I was opposed to the way it was presented to 23:45 me yeah because I quasi staged yeah well I mean it was like you you like we were 23:51 getting dressed down because nobody else would participate but I will say that we started doing those things regularly and 23:58 other people did start to open up and some of those meetings were really 24:04 really good and beneficial I think not just for the individual who was presenting the information but for 24:10 everybody the community that was in that room yeah exactly yeah I mean that can be so powerful absolutely and 24:17 encouraging you know you get reinforced that you're not saying it wrong you're not seeing it 24:22 incorrectly you're handling it well according to the committee opinion and 24:28 that's positive affirmation and we all appreciate positive affirmation so let's Circle back to what the original topic 24:34 was which was the most important question in therapy and this idea of the 24:41 difference between an open-ended and a closed-ended question what's the difference between so a couple things 24:46 occurred to me one is when clients becoming new clients would come in sometime in the first session or two one 24:53 of the questions that I would ask is if our work together is productive and 25:01 positive and on target how will your life be different if what we do together is beneficial for you 25:08 what will be different what are you looking for do you know do you think do you feel 25:15 your relationship your mother be improved your relationship with your mother will be severed you'll get out of 25:20 bankruptcy who knows what it's going to be but you have a concept of that so 25:27 then they start talking and what that does is sets for the 25:33 therapist if not the client what the goals of therapy are so a lot of times people talk about oh you had to have 25:39 goals and you got around but it doesn't have to be that formalized that question right there helps me as the therapist 25:45 understand that may be you know what the client says in in response to that 25:51 question might be what they're looking for but it might not I mean it might just be what they're talking about 25:57 because they haven't they don't feel safe enough to really peel back the layers of the onion yeah yeah right 26:03 right but but those are ways of establishing goals in therapy so if you're a new therapist and you're asking 26:10 that question what you're getting the information you're getting back helps you to understand where the client might 26:17 want to go in the therapy session and so as you listen to a client 26:25 one I mean there are different labels and skill techniques that this discusses 26:31 but you you listen to the phraseology and the verbalisms that they use 26:39 and that helps you learn how they think and how they experience 26:45 neuro-linguistic programming is a term and you listen to what they say and you 26:51 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 26:59 I'm picking something up here it's not in focus it could be me that's out of focus but 27:06 it could be you and so give me some feedback you're not getting this 27:11 accurately are you struggling with this did you just twitch did you just have a flash of a distraction or a thought and 27:17 you that's called uh I think it was a call it just went blank 27:24 uh silent uh okay uh I'm I lost it okay well but so a 27:34 closed-ending question is in question that can be answered with a single word so if I say did you go to the store 27:40 yesterday yes sir you can say yes or no yeah on which store right but an open-ended question it requires more of 27:48 an elucidation so if I say to you you know what it was your fun this childhood 27:54 memory and you say Saturday well obviously it requires more input than 27:59 that so in therapy we're trying to ask open-ended questions because the answer 28:08 that is provided by the client could give us additional information that's 28:14 more than Justice it gives you a directional approach but but there is one open-ended question that you never 28:20 ever ever ever ever ask you like me everybody always does no why oh yeah 28:26 yeah yeah I lost my temper and punched my questioning us why would you do that 28:31 why do you lose your temper I don't know how they're going to answer that yeah so 28:36 you don't say why so you don't ask open-ended questions that put the client 28:43 in a down position no you don't do that 28:49 you ask them exploratory questions yeah how do you understand that how did you 28:54 experience what did it feel like yeah uh well and then so now you're going back because I asked you originally what was 29:01 your most important question in therapy but I never answered that for me it is 29:06 how do you feel about that because emotional regulation is so much a central part of how I see human 29:15 pathology that that for me is the most important question how do you feel about that I think most people answer that 29:20 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 29:28 first things that I do is to train clients that if I say how do you feel 29:34 about that you have to answer glad mad sad or scared you can't because if you 29:39 don't use an affective AFF ECT affective word which is the psychological word for 29:47 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 29:54 disrespected well you can't feel disrespected that's not a Feeling you can think that you were disrespected and 30:00 let's assume for the sake of argument that you did think that you were disrespected how do you feel about that 30:05 well I felt angry okay now we're talking about affect and so I train people to 30:11 use that affective language so that and as they start to go through therapy they 30:18 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 30:25 having those affective conversations rather than just talking about how they think because you're absolutely right 99 30:32 of us 99 of the time when we are asked how we feel we tell people what we think 30:38 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 30:45 this little anecdote but uh when I was working at the hospital there was another guy that worked there and 30:52 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 31:02 response to everything that anybody said in group was anger about that anger 31:09 about that yeah anger about that and I said to him one day you know there are more emotions than 31:17 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 31:23 did that make you feel but he would just always say anger about that and yes maybe the person was angry but maybe 31:31 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 31:37 is that most people in our society at least and I think in the 31:43 world in general use anger as a way to cover up hurt and a part of therapy is 31:50 to go deep enough to help people recognize the way that they might be 31:55 covering their emotions with other emotions camouflage yeah yeah accurate 32:00 reflective listening yes what I couldn't remember so important yeah essential the 32:06 music that appears inside with Mike is written and performed by Mr Benjamin declue what we would love is if you are 32:13 a regular listener to the show or even if you're not even if you this is the first time you've ever heard the show if you're irregular yeah go to Apple 32:20 podcasts and find psych with Mike and rate US and leave a review that is super super beneficial we would really really 32:27 like it if you would go on to the YouTube spine psych with Mike and subscribe to the show there that is very 32:34 very helpful and as always if it's Friday it's psych with me foreign 32:41 [Music]