Psychotherapy Integration: Knowing What Works

By Elizabeth Dickson, LCSW

 

Knowing What Works

 

Determining What Works: The Role of Client Feedback

It makes no sense to introduce the concept of a therapist’s navigation system without also discussing the bigger system that it is a part of, namely the system of the therapist and the client working together. Just as the therapist’s navigation system is steering its course and guiding the therapist’s behavior and interventions, the skilled therapist also is absorbing (as much as possible) every aspect of the client’s reaction and is factoring that in as the most important input in the process. In our postmodern time of multiple truths our ability to be sensitive to and correct our course based upon client responses is essential in guiding our way. Since we don’t know any ultimate truth, how else can we navigate but to be vigilant to our client’s feedback and have some way of reading these responses to determine if what we have done “works”.

Client feedback is available at all points in the psychotherapy process and in many different forms. For example, we can ask at the end of the session for specific feedback as to whether and how the session was helpful or not helpful—and doing so has actually been shown to be one of the more powerful variables in predicting successful psychotherapy experiences. And certainly the ultimate feedback over the longer-term is that we can witness how the client is progressing (or not) in therapy. Are they happier? More fulfilled? Feeling more empowered and less stuck? Have they met the goals that they set out to achieve when they first came for help? But the feedback that I am focusing on here consists of all the information that is provided in each moment from the client that the therapist can potentially observe or take in that can influence the therapist’s navigation process.

Yet how do we make use of this information? How does a therapist evaluate (consciously or unconsciously) the feedback that they receive from a client on a moment to moment basis? What kind of experience are we hoping that our client will have? For experiential therapists, we might say that we want our clients to be touched in the process in a way that leads to growth and development. The advantage of the word “touched” is that it suggests something fresh and new, something that is felt in a palpable, bodily way and at the same time can encompass a wide range of experiences. It can mean emotionally touched (including the painful moments as well as the sweet or poignant ones); it can mean touched by the truth of a new insight; and it can mean touched in the many ways that clients and therapists are touched in the psychotherapy relationship.

 

The Experience of “Felt Meaning” as One Definition of What Works

To explore this more fully, I will introduce the work of Eugene Gendlin and his Philosophy of the Implicit. Gendlin is an American philosopher and psychotherapist who has taught many years at the University of Chicago and has a great deal to say about what the experiential dimension is, why it is necessary for successful psychotherapy, and how we as therapists can best utilize this experiential component in our work. In addition to being recognized for his extensive philosophical writings, Gendlin is also known as the founder of Focusing, a specific therapeutic approach that emerged from his collaboration with psychologist Carl Rogers.

Gendlin’s approach to what works is based upon his understanding of “felt meaning”—when something becomes meaningful to us, not just in an intellectual way, but more as if our whole being senses that something is meaningful. He is fascinated with what he calls an “implicit” domain that we all have within us which is infinitely intricate and which can be made explicit by finding the right words or images. He describes a “felt sense” as something that “forms at the border zone between conscious and unconscious” (at the edge of awareness), comes to us in a visceral way, and represents a whole complexity.

When clients are touching in to a felt sense, there is always an element of discovery, and this continues when the right words or images are found to express what is there. We know when we’ve found it because we can feel the shift, in the same way that we can feel the relief or release of an “ah-ha moment”. Gendlin calls this the forward movement of a felt sense. We as therapists depend upon this interplay between the implicit and the explicit for therapy to be successful. After all, our clients are not just repeating what they already know, but are allowing thoughts, feelings, images and reactions to emerge out of their lived experience in the therapy process.

Gendlin would probably say that all the forms of touching that I mentioned above are part of his concept of felt sense, that it can include emotion but is not the same thing as emotion. It is more like a whole bodily mood. Emotion sometimes accompanies the felt sense, but the felt sense also includes the bigger experience, the “place where the tears come from”.

Studying Gendlin can help therapists recognize, encourage and evoke this felt sensing and process of forward movement for our clients. We can think of it as learning how to “facilitate emergence”. Moments of emergence in therapy can be quite dramatic in a beautiful way, which is ironic since what is emerging or newly felt by a client sometimes comes from a part that has been hidden and that may be associated with shame or vulnerability. When a client finds (or hears from the therapist) just the right words or images to express their deeper felt sense, the feeling of release can be palpable. But even though we welcome the dramatic moments of discovery and epiphany in therapy, much of this process happens in more subtle ways and in small steps.

 

Utilizing Multiple Theories and Approaches: How Do We Find Our Way?

Identifying what works in this way can give eclectic and integrative therapists more of a map of how to proceed. In his book, Focusing-Oriented Psychotherapy: A Manual of the Experiential Method, Gendlin uses the concepts mentioned above to explain how therapists can incorporate a wide range of methods (including cognitive approaches, role play, dream interpretation, imagery, emotional catharsis, action steps, working with the body, etc.) while maintaining an orientation where direct experiencing remains central. And it is all predicated on the therapist’s ability to read and take into account the client’s responses to their interventions. I was surprised and pleased that the founder of Focusing (which emphasizes staying close to a client’s felt sensing process, as well as pausing and leaving space for the client to find their own way) would also endorse an integrative approach including some techniques that, at first glance, might appear incompatible with classic Focusing.

The bottom line for Gendlin is that therapists “can check each move they make, to see if it carries the felt sense forward or not.” If a therapist is sensitive to whether an intervention has been effective in evoking or lifting out a client’s felt sense and/or helping to move it forward, then the therapist can feel more grounded and potentially freer to try out different concepts and approaches. And then there need be no limit or danger in using a wide range of theories, concepts and approaches as long as they are not seen as representing reality, but rather as being helpful or not helpful to the client.

According to Gendlin, one can entertain different approaches because, “…each avenue becomes a way to lead to a felt sense. And, once there is a felt sense, all avenues are ways to carry it forward. From a felt sense the next step can come as words, an image, an emotion, or an interpersonal interaction.” We can think of his framework as guiding the therapist to find interventions that will point to, lift out or otherwise help carry forward the client’s felt sense.

Certainly all therapists use their navigation systems to take client responses into account, but so much of this is done implicitly and without a clear sense of our intentions. Gendlin’s system offers a precise way to conceptualize how client feedback in any given moment can guide the psychotherapy process for the integrative therapist. I believe that his philosophy provides just the kind of vantage point we need to begin to peer into the “black box” of psychotherapy integration.

 

Observing the Psychotherapy Relationship to See What Works

We might enlarge this framework even further to think about what works in the context of the psychotherapy relationship. As Gendlin says, we are not separate entities. Rather, “we are interaction,” so any forward movement of a client’s felt sense is never independent of the relationship that is occurring in that moment with the therapist. We are not just observing the client in isolation when we attempt to see what works; we are observing the client in relationship to us. We can be aware of all three dimensions: our own thoughts and feelings, our sense of what the client is experiencing, and how the two of us are together.

Just as we observe whether therapy is helping a client heal and grow, we can also observe how the psychotherapy relationship is evolving. In their paper, “The Development of the Dyad: A Bidirectional Revisioning of Some Self Psychological Concepts,” Lynn Preston and Ellen Shumsky propose that we look at the evolution of the analytic partnership as “one lens through which the analyst can envision the movement of therapy.” How well the relationship is developing gives us more information with regard to the question of whether or how the therapy is working.

What might be the qualities of a dyad that suggest that therapy is working? Preston and Shumsky believe that the growth of the psychotherapy relationship can be measured by “increasing intimacy, aliveness, vitality, resiliency, flexibility, depth, the capacity to negotiate conflict and difference, the building of trust and openness, the capacity to include a wider spectrum of feelings, and the expansion of each individual’s relational repertoire.”

And, in any given moment, we as therapists can be aware of how the relationship feels. What is the sense of the “us” from moment to moment, and how might that influence the decisions we make and the tone that we set as therapists? And what kind of “us” moments are we inclined to see as working or not working? Certainly we cannot imagine a navigation system without factoring in the tremendously important dimension of our sense of the psychotherapy relationship, both at a given point in time and also over time.