Can Taking Therapy Out of the Office Improve Outcomes?

Many of us have a short stack of books that have greatly influenced our work. One of mine is Deborah Tannen’s, You Just Don’t Understand: Men and Women in Conversation. The lightbulb moment for me occurred after reading this statement: “At every age, the girls and women sit closer to each other and look at each other directly. At every age, the boys and men sit at angles to each other—in one case, almost parallel—and never look directly into each other's faces.” Tannen draws from extensive research that illustrates how communication styles between men and women often differ and proposes reasons why this may be the case.

Along the same lines, I recently came across a well written Psychology Today blog by Dr. Audrey Nelson, the author of You Don't Say: Navigating Nonverbal Communication Between the Sexes. In her recent blog post, Why You Stand Side-by-Side or Face-to-Face: The secret science of posture and position, Nelson provides a concise set of theories on why men are more apt to favor a side by side approach (and with the author's permission I'm sharing these four theories here):

• Direct eye contact can be construed as challenging among men; a face-to-face frame is a more competitive posture and stance.
• The side-by-side frame increases men’s comfort level and eliminates the feeling of “competition.”
• Men are not as interested in looking at the face or maintaining eye contact. It is not always a high priority for them to be able to read the other person; therefore, they do not take a direct body posture.
• A person in a dominant position—a male, in this scenario—usually makes less eye contact than a subordinate.

How can we apply this to the practice of therapy?

The conventional set up of most therapy spaces is two chairs facing each other. Sometimes, chairs are positioned at a 45-degree angle. However, in my observation, there is often no conscious thought on the part of the therapist as to the positioning of the patient and provider chairs. I’m not suggesting that all female patients desire a set-up that promotes face-to-face interaction, or that all male patients prefer a set up that minimizes sustained and direct eye gaze.

As a "Free Range" psychologist, I do think we should make conscious decisions about how we practice in relation to create an optimal therapeutic environment for our patients. So, I started to experiment with this when I transitioned from working with a largely female clientele to a largely male, prior-military population.

One of the most enjoyable and clinically fruitful experiences I had while at the VA was a partnership with a Navy Veteran who teamed up with me on several occasions to co-treat patients. In his role as a VA peer support specialist, he had more freedom than I had in some ways. He was sanctioned – and encouraged to do “out of the room” therapeutic interactions. This included taking veteran patients for a hike – what he called “walk and talks.” One day, I asked him if I might join him and one of our shared patients on one of these “walk and talks.” The experience was eye-opening to me – my patient took on another persona the minute we hit the trails. He trusted both of us, so that didn’t account for the change in his demeanor and openness – there was something helpful to him about the format of that session.

I continued to experiment with this and joined the peer support specialist for other “walk and talks” with other shared patients. The same thing happened – there was an expansiveness and increased level of comfort. I think this goes back to the work of people like Dr. Deborah Tannen and Dr. Audrey Nelson – it’s an application of principles they have articulated to the practice of therapy. We were doing a “side by side” activity and this was somehow releasing these veterans to be more open. Since then, I’ve seen the same thing happen repeatedly, during reunion weekends with veterans, which have included intentional “side-by-side” interactions to facilitate comfort with critical disclosures.

I also think it helps explain the success of the Discovery Channel documentary Operation Fishing Freedom. Jay Garstecki, a professional angler, takes veterans on a fishing trip. As they engage in the side-by-side interaction of fishing together, Veterans are able to unburden themselves through talking about traumatic experiences they have encountered. When you watch the show, you’ll notice that several veterans do make direct eye contact during emotionally pivotal moments, but this set up allows each veteran to regulate the amount of eye contact. I think this may be a critical factor in helping them feel comfortable to open up. In other words, if the eyes are indeed “a window to the soul,” having a degree of control over how and when they reveal themselves through direct gaze, may be an important element in creating effective healing interactions.

Jay’s current show covers Medal of Honor recipient Al Lynch in a deeply moving episode that allows Mr. Lynch to tell us “the story behind the story.” Here is a link to the show if you want to learn more or take a look – there is something in this method that may be worth applying in our work in the healing professions.