How Patients Work

“Why is it that everything I do ends up being a failure? Why was I even born? Why did my parents even bring me into the world?”

The above words come from a patient whose name is Evelyn. She’s seeing Laura, her therapist, for ongoing treatment for a history of self-injurious behaviors. She articulated those words in response to Laura asking her, “How has it been like overall?”

Laura, a very skilled therapist, remained silent [1], using the "10-second rule" while remaining engaged and using her body language to indicate her undivided interest in Evelyn.

Evelyn took this as carte blanche and continued, asking: “Why was I born where I was born? Why was I born into the family I was born into? Why was I born black? Why was I born poor? Why was I born to parents who were so uneducated? Why was I born the way I was born while so many other people have had it all working for them since they were born?”

Evelyn paused, looked at Laura, who was paying close attention. Then Evelyn resumed talking:

“I don't know why. I don't know why since I was a kid, my parents never liked me. I don't know why since I was a kid, my siblings never liked me. I don't know why since I was a kid, I was always the black sheep of the family. I don't know why no one ever liked to play with me as a kid. I don't know why my teachers never liked me. I don't know why I was never popular in school. I don't know why I could never concentrate on studying and getting my grades up. I don't know why I could never sit down to read a book entirely. I don't know why. I don't know why. I don't know what's wrong with me.”

What's Going On with Evelyn?

Most therapists have worked with patients like Evelyn, though many of them struggle to articulate themselves so eloquently.

Evelyn had not started her treatment so eloquently, either. She used to act out her feelings and thoughts without being aware of them. Within a safe environment, Evelyn was able to get where she is right now—verbalizing how she truly feels about herself, her beliefs about herself, how she perceives others, the world, life, her family, her past, and her present.

There are several questions worth exploring here:

1. What allowed Evelyn to go from acting her behaviors out, to now being present to them and having the ability to verbalize them?
2. What’s the difference between then and now?
3. How is Evelyn’s ability to now verbalize her thoughts and feelings going to help her, if at all?

How a Therapist Helped

What allowed Evelyn to go from acting out her feelings to now having the ability to verbalize them is working with a therapist—who not only knows the hard skills of psychotherapy but who also knows the soft skills, which, when absent, can often render the hard skills ineffective.

What are these soft skills? Here are 3:

1. The proper use of silence using the "10-second rule." This, in a nutshell, is the ability to wait for up to 10 seconds before responding to a patient, who like Evelyn, is narrating her story in such a coherent way.
2. The use of the clinician’s body language. In a nutshell, this is the therapist's ability to use her facial expressions, posture, hand and head gestures to engage her patient, establish rapport, show empathy, and encourage her to continue telling her story.
3. Appropriate use of eye contact using the "Triangle Technique." This, in a nutshell, is the skill for the therapist to properly connect with her patients in a way that shows that she is with them in the room, she is with them in her story, she even can see her humanity in that of the patients, without having to stare at them, intimidate them, or leave them uncomfortable with her gaze.

Now that Evelyn has been fortunate enough to have a clinician who knows the hard skills of psychotherapy and the essential soft skills, she’s been able to bring a lot to her awareness.

But as in the second question we asked above, what’s the difference between then and now? How does bringing it to awareness help her in any way? Here’s how:

1. Everything is thought, and this is the basis of CBT [2]. In other words, our feelings are simply the expression of our thoughts, and our behaviors are simply the expression of our feelings, which means our behaviors are indeed the expression of our thoughts.
2. Our thoughts being expressed as feelings can be great information for us to be aware of, to then refocus or shift our thoughts, as needed. However, without being aware of that or when we fail to refocus or shift, we are more likely to act those feelings out, as Evelyn used to.
3. The moment Evelyn makes the association between her thoughts, her feelings, and behaviors, things start to shift in a way that she neither could explain nor she could understand previously. What takes place is that Evelyn is now able to see something; as she sees it, it becomes conscious; as it becomes conscious, she can distinguish it, and distinguishing it is the key because the information is in the difference.

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In other words, before, Evelyn was confused about her self-injurious behaviors. Now she knows that her self-injurious behaviors were simply a response to her feelings and she has stopped that. Next, she understands that her feelings are only the expression of what she is thinking, while also understanding that what she tends to think reflexively (known in CBT as automatic thoughts [3]) is simply a reflection of her beliefs (known in CBT as core beliefs [4]).

Now, where Evelyn is at this time is being in touch with her beliefs. She’s currently processing her beliefs about her parents, herself, and others, which is a great place to be compared to being unaware of the beliefs that run our lives. This is the start of what’s next for Evelyn, and in a subsequent article, we will see what happens next for her.