Identity and diagnosis

I’ve  written two prior posts on the paradox of identity, and now I want to return to the topic. I’ve run into different versions of the  following affirmation/mantra and I don’t know who to attribute it to, but it’s a good starting point for this brief examination of what identity is and isn’t: “I have a body. I am not my body. I am more than my body. I have emotions. I am not my emotions. I am more than my emotions. I have thoughts. I am not my thoughts. I am more than my thoughts. ” For people with identified mental illnesses I’d add: “I have a diagnosis. I am not my diagnosis. I am more than my diagnosis.”

Folks grappling with mental illnesses often find themselves stigmatized, treated as the modern equivalent of lepers, although they’re not contagious. Even within the mental health community individual patients are sometimes referred to by clinicians as “a schizophrenic” or “a borderline.” Mentally ill people often sense that others stereotype and define them by their mental illness. One of my great revelations early in my career (I already knew it intellectually, but not experientially) was that people with mental illnesses are, first, unique individuals – like the rest of us. Their mental illness is a feature of who they are, not a defining characteristic.

When I worked in a Dialectical Behavior Therapy (DBT) program, designed to help “borderlines,”  one of my individual therapy clients was a highly intelligent and assertive  woman. She let me know up front in our first therapy session that she wouldn’t abide being referred to as ” a borderline” by me or my colleagues. “I’m a person who meets the diagnostic criteria  for  Borderline Personality Disorder.” And that describes her better than any diagnostic label. (Years later she saw me at a mental health event and gave me one of the finest and most honest compliments I’ve ever gotten from a former client. She said that I was the second-best therapist she’d ever had.) She refused to let others define her by her diagnosis, and was her unique self. I’ve worked with a number of people diagnosed with Borderline Personality Disorder, and no two of them were alike. I’ve worked with many more who carried the diagnosis of schizophrenia, and no two were alike.

It’s easy to stereotype people we don’t understand, and whose behavior might confuse or threaten us. As with homophobia, fear of crazy people – the most common stereotype –  is rooted in the unconscious or conscious fear, “what if I were that way.” The idea of “losing your mind” is frightening to anyone who thinks about it. Les aliens is a French term for the insane. Many people with chronic mental illnesses feel internally alienated because of their symptoms, whether depression or hallucinations. But on top of that, mentally ill people are frequently treated as aliens by people who don’t understand, and therefore fear, them.

People struggling to cope with the symptoms of mental illness often find themselves judged or blamed for their symptoms. A person in a manic state may be told, “Just pull yourself together and stop acting crazy!” A person suffering from clinical depression or PTSD might hear, “What’s wrong with you, anyway? You should have gotten over that by now.”, as if they had a choice.

Psychodiagnosis is a necessary part of the medical model but, as discussed in a previous post, it’s based on decisions made by committees and applied to unique individuals. It’s not rocket science. Psychiatry puts the people it treats in the patient role, or sick role. There are both advantages and disadvantages to being conferred the sick role. It absolves you of responsibility for certain things you’d normally be held responsible for; but it prescribes what you must do as a patient, and often keeps you dependent on ongoing treatment. This makes sense for a kidney dialysis patient, but not necessarily for everyone with a psychiatric diagnosis.

In some circumstances, for mentally ill persons there’s no substitute for good psychiatric treatment. But all too often patients are told that medication is the only option, and that they’ll have to depend on medications with awful side effects for the rest of their lives. The recovery model is person-centered, not patient-centered. Centers run on the recovery model work with their clients to come up with a unique recovery plan that serves to empower them, encouraging autonomy and hope. The plan may include referrals for psychiatric treatment when it’s needed, but other options are explored. More about the recovery model soon.

Anger management

I’ve taught anger management to groups of police officers, incarcerated felons, Marine drill instructors, and school teachers, as well as to many individuals – some of them referred by the Family Court. A lot of people with anger problems are highly resistant to attending anger management classes or counseling sessions, so I’ve had to learn how to get past people’s defenses if I was going to help them.

My definition of anger management took a lot of people by surprise. “Anger management,” I’d say, “doesn’t mean that you don’t get angry anymore, or that you can control when you get angry. Everybody gets angry, and sometimes anger can be a good thing. Anger management simply means that no matter how angry you feel, you can still make good decisions and you don’t do things you’ll have reasons to regret later. It means that you don’t let your anger control you.”

Nobody has absolute control over their emotions. Sometimes we feel carried away by them; it’s part of the human condition. People aren’t accountable for what they think  and feel, but for what they do. In certain situations, like combat, anger may help you to survive. But if your anger creates problems in your life, you can learn to stay in control of your behavior when angry. In order to do this you first need to understand some things about how your anger affects you: your personal triggers and cues, and your choices.

The roots of anger in childhood. You’re less likely to have anger problems if you grew up in an environment where your primary role models practiced anger management. Some parents know the right words to say to their kids: “Just because you’re angry at your brother, that doesn’t give you permission to hit him.” But role modeling works better than lecturing, and if adults can’t practice what they preach, their children learn more from what they do than from what they say. If you grew up with physical or emotional or sexual abuse, you’re not necessarily destined to have anger problems, but it’s more likely that you will. Bad tempers aren’t an inherited trait; but if you have one, you probably came by it honestly. If we were taught by our social environment that violence is a solution to interpersonal conflicts, we need to learn that there are better solutions.

Abraham Maslow said that if the only tool you have is a hammer, you’re likely to treat every problem as a nail. Some people learn to rely on anger and physically- or verbally-aggressive behavior, using intimidation tactics and threats to get their way, and resorting to violence when they don’t. Sometimes people take out their anger, not on the person who triggered it, but on those weaker than themselves. Dad yells at Mom, then Mom smacks Junior, who kicks the dog. It’s called displacement.

Triggers. The first step in learning anger management is to be aware when you’re angry. This may sound elementary, but often people who are angry are focused on externals, not on their here-and-now feelings. “I’m not ANGRY, you messed up!” People have different triggers for anger, and awareness of your triggers can help you to own what you’re feeling right now, and take those feelings into account when you choose how to respond to the situation. Sometimes the best thing to say is something like, “Look, I’m just too angry to continue this now. Give me time to chill and we can take up where we left off.” Personal insults, taunts, or sarcasm may or may not be triggers for you. Tone and loudness of voice, and body language, may be triggers if they remind you of someone with similar features. Situations (i.e. traffic jams) can be triggers. We all have identifiable triggers, and it helps to know what they are.

Cues are physical sensations we predictably experience when we’re in a specific emotional state, although a focus on the triggering experience might eclipse our awareness of our subjective state. Common cues for anger are a rapid heartbeat, heavy or rapid breathing, tensed muscles, a flushed face, and an adrenaline rush. Awareness of your cues in the here-and-now can help you to recognize and own your anger, and make good decisions despite it.

Owning your anger means not blaming others, or external circumstance like traffic jams, for what you feel. As a therapist I’ve encountered many people who typically, reflexively blamed others for their feelings, rather than owning them. “You make me so angry when you talk to me that way” is a cop-out, a manipulation. If others are responsible for your anger, then they need to change their behavior to stop “making you mad.” The idea that others will always have the power to make you mad puts you at a disadvantage in relationships. It’s much more rational to think of it as, “When you talk to me that way, I get angry.” If you don’t own your anger, you give away your personal power. If you own your anger, you can learn how to make decisions you can live with, no matter how angry you are at the time.

Physical anger management.  Here are some suggestions for physical things you can do to deal with angry feelings. (1) Vote with your feet. Walk away from the triggering situation, if that’s an option. Stay away until you calm down. (2) Slow your breathing. You don’t have an on/off switch for your anger, but breathing slowly has a physiological calming effect. (3) Physicalize your anger. Once you have the opportunity, release your anger by exerting yourself in harmless ways: do pushups, run, shadowbox, work out on a punching bag, or whale away at your bed with a pillow.

Mental anger management. In teaching anger management, I’ve compared anger to building a campfire. You can’t start one without an initial flame or spark, and once it’s started you need to keep adding fuel, or it will go out. First you ignite twigs from the spark, then you throw branches on the blaze, then logs. Anger is like that. It starts with a spark (trigger) and needs fuel to grow. The fuel that’s required for momentary anger to grow into a rage is angry thoughts. All people engage in self-talk. Some of it helps us to feel compassion for others and to make rational decisions, some of it can lead us to do irrational things that we’ll regret later. Rational self-talk (“She didn’t mean to hurt my feelings.”) can extinguish a blaze of anger, while irrational self-talk (“He needs to get his butt kicked!”) can turn a spark into a bonfire. Rational thinking will be a continuing topic here. It’s a cornerstone of cognitive therapy.


Freud’s legacy

Freudian psychoanalytic theory was the basis of the whole notion of  “the talking cure” – what we now know as psychotherapy. But many of Freud’s ideas have been discredited and none (to my knowledge) have stood up under the lens of scientific scrutiny. This doesn’t necessarily mean that they have no utility, just that they can’t be proven. I’m not suggesting that nobody has benefitted from psychoanalytic therapy, but its techniques and benefits haven’t been empirically validated.

The first two editions of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) were largely written by psychoanalysts, and analyzed mental illnesses through Freud’s theoretical lens. (Both editions labeled homosexuality as a mental disorder, a grave error corrected in the third edition.) Subsequent DSM editorial committees saw fit to question the utility of Freudian concepts such as neurosis and hysteria, and to focus instead on identified symptoms in establishing diagnostic criteria. Most of Freud’s psychoanalytic concepts have proven superfluous to our understanding of the pathologies, or unfounded.

Freud attributed most psychopathy to unconscious and unresolved infantile or early childhood issues and conflicts, especially those conditions he characterized as “hysterical” or “neurotic.” He posited that the Oedipus Complex was a universal experience for little boys: the unconscious wish to kill Dad and have sex with Mom. The Electra Complex was the female analogue of this Freudian notion, which no longer seems to have any utility. The concept of female “penis envy” also appears to tell us more about Freud’s psyche than about the human condition.

While there may be some metaphoric validity to the idea that some people are “accident prone” or have a “death wish” due to unresolved unconscious conflicts, there’s no real evidence for these propositions. Conversion disorders – the loss of some physical or sensory capability for psychogenic reasons – are still in the DSM, but calling them “hysterical” in origin contributes nothing to our understanding of the condition.

There’s been a steady decline over the years in people who undergo the rigorous training required to become a psychoanalyst, and its theory and techniques haven’t been validated by research. The technique of “free association” (saying the first thing that comes to mind, in response to serial stimulus words) can reveal interesting mental associations, but there’s no scientific evidence of its effectiveness as a therapeutic technique. Dream analysis can be fascinating, but it’s not a magical key to insight.

I’ve already written a post in which I presented Freud’s concept of defense mechanisms as a useful tool in psychotherapy. But what other Freudian notions have stood the test of time? In my opinion, his popularization of the concept of unconscious motivations has contributed significantly to our understanding of human behavior. Sometimes people do things for reasons they don’t consciously understand. This idea has taken root in modern life.

The personality structure of superego, ego and id still has some metaphoric validity, and was revived in Transactional Analysis as parent, adult and child. The way I used the metaphor in therapy went something like this: “It’s as if we had three aspects to our personalities, the parent, the adult and the child. Children operate on the pleasure principle – I want what I want right now! One of the tasks a child needs to master on the journey to adulthood is learning to delay gratification, to be willing to do needful things now, in anticipation of future reward.”

Another Freudian concept that still makes sense to me is that of transference and countertransference. It describes emotional dynamics within a therapeutic relationship. Freud said that patients tend to unconsciously transfer feelings for significant others (like Dad , or a lover) onto their therapist. A therapist who is aware of this dynamic in the therapeutic relationship, and who isn’t unconsciously affected by countertransference (her feelings for the patient), can use transference to the patient’s benefit in therapy. A client falling in love with his therapist or a therapist falling in love with her  client (it happens) can also be understood through this Freudian lens.

But it seems to me that Freud’s most enduring legacy (influenced by his mentor, Joseph Breuer) was his concept of “the talking cure,” the idea that talking about your problems with an attentive and caring therapist can be healing. This may seem obvious to many of us today, but without Freud’s contribution, contemporary psychotherapy as we know it wouldn’t exist.

Bonus recommendation: If you want to read an excellent novel about the genesis of “the talking cure,” I highly recommend Irvin Yalom’s When Nietzche Wept. Freud isn’t the main character, but the novel imagines a friendship between Joseph Breuer and Friederich Nietzche, and how it affects the lives of both men. Don’t waste your time on the movie adaptation.


The model muddle

I’ve already written posts on several therapy models (gestalt, Rogerian, Transactional Analysis, Freudian psychoanalytic), so it’s time I examine what models are: their utility, their strengths, and their limitations. First off, models are ways of organizing and framing ideas in a way that serve as a guide. A good model is like a good map: it helps you accomplish something you set out to do, to get where you wanted to go.

But the map is not the territory; it’s merely a helpful representation. I’ve known people who were so dedicated to a model that they couldn’t see its limitations, and were blind to alternative formulations, viewing everything through the lens of their fixed beliefs. No model is perfect and complete. Each one has its flaws and limitations.

I first started thinking about models as a young mental health professional, when I read Miriam Siegler and Humphrey Osmond’s Models of Madness, Models of Medicine, in which they compared the medical model to eight other models related to the care of mentally ill persons. After examining each model (moral, impaired, psychoanalytic, social,  family interaction, etc.), the authors – both MDs – conclude that psychiatry is the only way to go. Holistic, shmolistic..

Psychiatry is the medical model’s approach to treating mental illness, usually with medications. The medical model is a scientific model. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to a specific treatment. The medical model is very good at what it’s good at, such as mending broken bones, and doing surgery, and treating many physical ailments. But its self-promotion as the only game in town for the care of the mentally ill has been challenged by many, notably Dr. Thomas Szasz and R.D. Laing.

No model is a perfect fit for all occasions, and many MDs have come around to believing in the benefits of a holistic approach to health care. Although I still believe that psychiatric treatment has its place and can be of benefit to many people with what are known as “psychiatric disorders,” like all models the medical model has its limitations. There are other valid approaches to health care that don’t rely on symptoms > diagnosis > treatment as their primary focus. The medical model is mostly focused on what to do after you exhibit symptoms, not so much on how you got there. Some medical traditions are more focused on wellness than on treating (sometimes preventable) illnesses. No model has all of the answers.

One of the limitations of the medical model as regards the care of mentally ill people is that the criteria for a differential diagnosis were determined by a committee of psychiatrists, to be applied to a unique individual. Unlike most physical disorders, there are no identifiable biological markers to distinguish what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psycho-diagnosis is not rocket science, because mental illness isn’t precisely measurable. At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

A model I’ll be writing about in a future post is the Recovery Model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” chronic substance abusers, but did it apply to the chronically mentally ill? I think (hope) that many or most mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers in some cities that aren’t run on the medical model. You might want to check out <> to learn more.

Treatment models compete in the marketplace, and there’s money to be made. For instance, the Pentagon has paid millions for training in Positive Psychology. With modern marketing in the mix, we find ourselves in the midst of a model muddle. More about this down the road.

Defense mechanisms

In the classic boomer movie “The Big Chill” Jeff Goldblum’s character asserts that rationalizations are more popular than sex. When his friends look at him questioningly, he asks, “When was the last time you’ve gone a week without a rationalization?”

Many of Sigmund Freud’s psychoanalytic notions have been discarded as the art and science of psychotherapy has evolved, but one of his contributions has, I think, proven valuable over time: defense mechanisms. Dr. Freud and his daughter Anna described specific ways that people defend themselves from frightening or unacceptable thoughts, feelings, or memories. A thought may be unacceptable because it threatens our cherished self image, or because it might open a door we’d rather remained closed. Freud said that to the unconscious mind, a wish is identical to an act. As a therapist I’ve seen many people who had terrible guilt for having had unacceptable thoughts or feelings, although they’d never acted on them, and didn’t want to.

I don’t intend to cover all of the defense mechanisms in this post, but here are some of the things people do to defend themselves against the unacceptable: denial is an extreme form of avoidance. “If it’s not true I don’t have to deal with it.” Confronted with mounting evidence that she’s lost control of her drinking behavior, denial will allow an alcoholic to continue drinking, because the thought of getting and staying sober is terrifying. Denial that a loved one is dead allows you to avoid the pain of mourning.

In therapy I’ve described avoidance  as being a surefire drug that always works to eliminate here-and-now anxiety, and therefore can become an addictive habit. Take the case of someone who’s been unfaithful to his lover on one occasion, and knows he has to admit it, because it will eventually come out anyway. So he promises himself he’ll tell his lover about the one night stand by the end of the weekend. He puts it off until Sunday, and as the day goes on his anxiety mounts. Will his confession wreck the relationship? As midnight approaches, he decides to postpone his confession (a kind of avoidance), and immediately experiences a reduction in here-and-now anxiety – as if he’d taken an anti-anxiety medication that works instantly. That immediate relief from anxiety is “reinforcing” and increases the likelihood that he’ll resort to avoidance again. In this manner, defense mechanisms can become habitual.

Habitual avoidance can perpetuate dysfunctional or irrational behaviors. If your response to a deep-seated fear of flying is to never fly, your avoidance reinforces your irrational fear. You may want to travel to Europe and may understand intellectually that air travel is statistically safer than driving, but the prospect of giving up all control and entrusting your life to the pilot may seem intolerable. Fear of a real threat is a reasonable response, but phobias (irrational fears) only serve to limit our options in life.

The only effective way to overcome phobia-based avoidant behaviors is what cognitive behavioral therapists call “exposure.” To get over your fear of drowning, you have to (eventually) swim in the deep end of the pool. Only by facing the thing feared can you grasp that the fear was irrational. This principle also pertains to regaining confidence in something you were good at, but now avoid because of a bad experience. We all know what you’re supposed to do if you’re afraid to mount any horse because another horse threw you; but that doesn’t make it easy. You either get back in the saddle, or you avoid horseback riding.

Having started with rationalizations, I’ll conclude this post with some thoughts on that defense mechanism, also known as intellectualization. I’ve found that highly intelligent people who have risen above the “more primitive” defenses of denial and avoidance have found rationalization as their anti-anxiety drug of choice. The essence of rationalization is,  “I don’t have to deal with it if I can explain (rationalize) why I don’t have to deal with it.” Or “I’m not responsible because I have an explanation.” Or “I didn’t want that, anyway.” The fox in the Aesop fable about the fox and the grapes is a classic representation of an intellectualizer in popular literature. When he couldn’t reach the grapes, he concluded that they were probably sour.

Like denial and avoidance, intellectualization gives a temporary respite from unwelcome thoughts and feelings, but like the other defense mechanisms it can perpetuate dysfunctional behaviors. Defense mechanisms are often barriers to insight and personal growth. I’ll write more about them later.


Communication and metacommunication

This post will explore some of the basics of Dr. Eric Berne’s Transactional Analysis (TA), one of the popular theories in the humanistic psychology movement, and will also briefly cover “metacommunication” as a principle in communication theory. Eric Berne is perhaps best known for his book The Games People Play, which popularized some of his concepts regarding TA – a psychoanalytic theory. Another popular book about TA was I’m OK, You’re OK, by Thomas Harris.

Communication theory posits that every statement made within a relationship works on two levels: the content of the statement, and as a statement about the nature of the relationship. So I’ll start with some thoughts on what a relationship is and the different kinds of transactions that occur in relationships. A relationship can be a casual ongoing series of social transactions, such as your relationship with your postal carrier or a store clerk whom you see from time to time, or it can be something deeper. Dr. Berne listed the kinds of transactions that occur in relationships, from the superficial to the intimate.

The most basic transactions are what Berne called rituals, polite exchanges that superficially acknowledge a relationship, but contain no real, meaningful content. “How are you doing?” “Oh, I’m  fine. Hot enough for you?” The next level of transactions is pastimes, where two or more acquaintances pass the time together, watching TV or playing a game, with no sharing of meaningful content. After that is activities, where people get together to engage in purposeful pursuits, with a goal in mind, without getting past superficial interpersonal exchanges. In the next level of transactions, games, there’s an effort to connect and share meaningful communications, but the people involved engage in inauthentic manipulations. It was this level of transactions that Berne primarily focused on in The Games People Play.  A popular song borrowed its title: “Oh the games people play now/ Every night and every day now/Never meanin’ what they say now/Never sayin’ what they mean.”

TA is a psychoanalytic theory because it re-casts Freud’s superego, ego and id as parent, adult and child, and analyzes games in relationships within that framework. I’ll write about games and crossed transactions in a later post. For now I’ll just say that the highest level of transactions in TA is intimacy: non-manipulative, authentic relating.

Having said that relationships can range from superficial to intimate, now I’ll elaborate on communication and metacommunication. On one level, any statement within a relationship is characterized by its content, whether it’s a “How ya doin?” communication that simply affirms that a relationship exists, or whether it contains more meaningful content. But on another level, metacommunication, the statement is a comment on the nature of the relationship. It’s as if every statement within a relationship were preceded by, “We have the kind of relationship in which I can say to you ______.” If you have no problem with the statement, then you and the person who said it agree on the nature of your relationship. If you find the statement creepy or inappropriate or offensive, there’s a disagreement about the nature of your relationship.

Take the example of a newly-single mother,  the night after Dad – who used to be the sole parental disciplinarian – moved out.  With Dad gone, Mom has had to take on that role. The first time Mom (in Dad’s absence) tells Junior it’s time for bed, she’s saying. “We have the kind of relationship where I can order you to go to bed.” If Junior complies, putting on his pajamas and brushing his teeth, he’s affirmed Mom’s new role. If he replies, “I’m not ready to go to bed yet,” he’s attempting to reject Mom’s new definition of their relationship, implying, “I don’t have to do the things you tell me to do if I don’t want to.” If Mom lets Junior stay up, she’s let him define the relationship. If she says, “Nine o’clock is your bedtime. If you’re not in your pajamas with your teeth brushed in ten minutes, no TV or video games tomorrow,” she’s asserting that she is the parent and gets to define the relationship.

Another example involves a woman who has just taken a job in an office managed by a lecherous boss. If, on her first day of work, he tells her “You look hot in that dress” and she doesn’t object, she’s  communicating that she accepts his understanding that “We have the kind of relationship where I can comment on your body and make suggestive remarks.” If she doesn’t want this kind of treatment to persist, she needs to reject his assertion as to the nature of this new relationship. “Mr. Smith, I know you meant that as a compliment, but I really don’t feel comfortable with you talking to me like that.” In saying that, she’s asserting that the relationship is professional, not personal, in nature.

I’ve found this principle of metacommunication to be very helpful in making sense of the complexities of human interactions. (Or, as Eric Berne would have it, “analyzing transactions.”)  You already know intuitively, from your own experience, the essence of what I’ve written about in this post; I’ve just given you the principle behind what you  know,  and given it a name. The term has another meaning that I’ll get into in a later post: within a relationship, metacommunicating means communicating about how we communicate, talking about how we talk together.


Client-centered therapy and active listening

Dr. Carl Rogers’ client-centered therapy was one of the major therapies within the human potential movement. I had the good fortune to meet him briefly when he was the keynote speaker at a convocation of the Association for Humanistic Education, held at West Georgia College (now the University of West Georgia) in 1976. I’d just listened to his address and then joined my ex-wife, Doris, who was selling her hand-crafted jewelry from a blanket on the lawn outside the education building. Dr. Rogers came out of the building and Doris’ display caught his eye. He was being escorted by a faculty member, but stopped to look. I can’t remember anything that was said between the three of us, but I was in awe of the man and couldn’t believe I was actually talking to him. He bought a piece of Doris’ jewelry as a gift, so I’ve subsequently made the claim that Carl Rogers helped put me through grad school.

Rogerian therapists don’t make analytic interpretations, or provoke authentic responses, or recommend goals to the client. Goals are established by the client, who does a lot more talking than listening in therapy sessions. A good Rogerian therapist is an active listener, who strives to understand the client’s sense of self, interpersonal boundaries, and experience of being-in-the-world by carefully listening to his words. The therapist might ask clarifying questions, but mostly listens. Actively.

After listening to a detailed account of a client’s issues with her dominating mother, the therapist doesn’t respond with an interpretation, but reflects on his understanding of her experience. “It sounds like every time you’re around your mother you end up feeling angry and worthless. I also heard you say that you keep having intrusive thoughts about your mother dying in an accident, and you feel terribly guilty about having these thoughts.” If the therapist has accurately and non-judgmentally reflected the essence of what the client was trying to express, this usually promotes increased trust and a fuller disclosure on the subject at hand. When the therapist is on the mark, the client knows that the therapist cares, listens carefully, doesn’t judge him, and seems to understand. If the therapist misses the mark, the client will usually let him know right away.

Often in everyday life we only give part of our attention to what others tell us, or are distracted by our own thoughts or reactions. Listening is often a passive act. Active listening means giving our full attention to what we’re being told, without allowing our thoughts to distract us. It’s a kind of mindfulness. In a different arena, music appreciation, certain kinds of music demand more of the listener than others. To fully appreciate chamber music, or a sitar raga, or jazz by Coltrane, you have to quiet your own thoughts and give your full attention to the music. In the interpersonal arena, sometimes we need someone who cares enough to listen actively when we have something important to say, whether that person is a therapist, a pastor, a spouse, a family member, or a trusted friend.

Active listening is a learnable skill. I started learning it in grad school. Even when I was working in a therapeutic mode other than client-centered therapy, I was an active listener. I’ve always believed that I owed it to each client to give them my full attention. Sometimes I’d do a brief meditation between clients, to clear my head. Like most things, you learn active listening by practicing it. You have to learn to suspend your own thoughts, and you do that by simply noticing any thought that intrudes on your active listening. Like a stray cat, if you don’t feed it, it goes away. Focus on listening without judging. You can practice listening actively to classical music or jazz, too. Learning to listen actively to complex music is its own reward. Active listening gets easier with practice.

When a parent would come in complaining that their child used to confide in them, but stopped, I’d coach them in active listening and non-judgmental reflection. When a child feels understood and validated, she develops higher levels of  trust and is more willing to talk about what’s important in her life. Learning to be an active listener will give you a tool that some therapists use to establish trust and encourage disclosure. It will make you a better parent, friend or spouse. When you listen carefully and reflect back what you’ve heard accurately and non-judgmentally, the person you’ve been listening to knows that (1) you care enough to (2) really hear them (3) without judging them and (4) you seem to understand and accept what they’re going through. Everyone (other than sociopaths) wants to be understood and validated, and you can help people you care about feel accepted as the unique person they are. In terms of personal growth, Carl Rogers  taught that self-acceptance is the fertile ground in which the seeds of growth can flourish.