One Size Does Not Fit All in Psychotherapy

It seems natural to hope that everyone who comes to therapy has a core set of interpersonal skills to make maximum use of it. In the “olden days,” therapists talked about the ideal patient as being YAVIS: Young, Attractive, Verbal, Insightful, and Successful. However, the idea that the patient must possess certain skills to get the maximum benefit of therapy limits the usefulness of it.

So, the therapist must continue to expand his repertoire of clinical approaches used in his practice. As an example, not long ago, I had a challenge that stretched my approach in working with a marital couple.

--------

So, here they were again, both clearly distressed. She said, “He did it again! I can’t imagine why he doesn’t get it.” Her frustration was clearly evident and he looked crushed.

She continued, “I woke up and saw him sitting at his desk; I asked, ‘Do you want to go to the gym?’ He silently got up and started to get dressed. I watched him a minute and then said, ‘It would have been nice if you’d asked if I wanted to go, too.’”

Now, I asked him what he heard when his wife asked if he wanted to go to the gym.

“She wanted me to go to the gym so I wanted to please her.” He had not heard her asking to connect with him by going to the gym together.

How could I explain Gottman’s bids for emotional connection so this man could understand? Although seemingly a simple concept, recognizing bids is a bit abstract and this man did not excel in that area. He was an engineer and, while he surely loved his wife and tried to do things he thought were nice for her, he kept missing cues that most people “get” and he and she were in my office because she was at her wit’s end in the marriage.

Then I remembered a model of communication I had taught nurses many years ago.

Sender → Message → Receiver

It is a simple model, often referred to as the transmission model or standard view of communication: information or content (e.g. a message in natural language) is sent in some form (as spoken language) from a sender/encoder to a receiver/decoder. This common conception of communication views it as a means of sending and receiving information. One of the strengths of this model is its simplicity and concreteness. Mathematicians Claude Shannon and Warren Weaver structured this model with the following elements:

• An information source, which produces a message;
• A transmitter, which encodes the message into signals;
• A channel, to which signals are adapted for transmission;
• A receiver, which “decodes” (reconstructs) the message from the signal.

Shannon and Weaver also recognized that often there is static that interferes with the transmission as with one listening to a telephone conversation, which they deemed noise. The noise could also mean the signal isn’t strong enough to get through the noise.

So, I told them both about the three-box model and drew it. I told him the middle box, the message, is filled with nouns – they could be anything: the gym, a sunset, something that happened that day. It isn’t those nouns that matter. It’s the fact that she is offering him that box of nouns that means she would like to connect. When he ignores that box, she feels disconnected. Perhaps he could ask for clarification if he is unsure whether what she was saying meant she wanted them to do something together or share something.

Suddenly, his face lit up. He got it.

But I realized the onus was not entirely on him. The wife also needed to be coached to “up the signal” to overcome any noise in the system. That is, she needed to be a bit more direct in her requests for connection even as he was learning to do something she thought came naturally to everyone but doesn’t.

They’re still working on tuning their communication and I was reminded again that, while psychotherapy has as its goal to help individuals (and couples) grow beyond learned or inborn limitations, sometimes the therapist must dig deeply into a conceptual duffel bag to find just the right approach to do that.

References

Schofield, W. Psychotherapy: The Purchase of Friendship. Englewood Cliffs, NJ: Prentice Hall; 1964

Shannon, CE, & Weaver, W. The mathematical theory of communication. Urbana, IL: University of Illinois Press; 1949.

Leslie Durr, PhD, RN, PMHCNS-BC is an advanced practice psychiatric-mental health nurse with a private psychotherapy practice in Charlottesville, Virginia.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.