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Inquiring Deeply into Psychological Problems

Psychotherapy invariably begins with an inquiry into why a patient has come. Most often I begin with some question like “what brings you?,” but there are many different ways to open the therapeutic dialogue.

Most often the patient gives a narrative about a problem they are having, frequently one which has been stubbornly recurrent and troublesome. One slogan which summarizes what I have learned in the process of doing this work is that “insight often begins with bad news.” I may or may not make this comment out loud, but it is an implicit part of my clinical paradigm.

Patterns of emotional reactivity, upsets, or “meltdowns”—places where there has been a breakdown in the capacity to metabolize emotional experience—are useful points of departure for inquiring into the psychological structures that organize experience. As we inquire about a problem, we first endeavor to trace emotional reactions to their roots in unmet psychological needs. Most often we discover that problems are rooted in our views of self and other.

The overall goal of dynamic psychotherapy lies in establishing a therapeutic conversation (and therapeutic relationship) which supports a deeper emotional understanding of the nature of the patient’s difficulties. At various points in the therapeutic dialogue, opportunities for reflective practice may unfold, as will be illustrated in the clinical vignettes which follow.

I will begin my description of this therapeutic approach with an entry from the journal of a patient, “Alice,” who used her meditation practice to investigate an experience of anxiety.

Clinical Illustration 3.1: Alice

I noticed that I was anxious. I tried to see where it was coming from [investigation] but it was opaque to me, so I decided to sit in order to explore what the anxiety was about. A lot of thoughts came up about a conversation I had yesterday with my sister regarding a fight she had with her husband [reflection]. Suddenly it became clear to me that I am upset about my relationship with John [Alice’s significant other]. I am worried that he may be attracted to Betty [a woman John works with].

I spent the rest of my meditation trying to locate the roots of my jealous feelings. I also thought about the nature ofjealousy, and what you said to me once about my tendency to confuse jealousy and love. I could see clearly that my jealous feelings are based on feelings of insecurity [self-reflection].

As she meditated, Alice had a spontaneous insight about the link between thoughts she had about her sister’s marriage and jealous feelings she has regarding her own partner. Had Alice and I been talking together, I would likely have had the same thought and said so. Clarifying and making interpretive links of this sort are among the basic skills of effective clinical listening in any psychotherapy.

Note that in the example given, inquiry began with the associative framework of psychological meanings, as in the example given. For most people, this is a very “natural” place to begin as we look within ourselves, because the raw material in the mind tends to consist of these kinds of associations. (In dharma practice, all of this would fall into the category of “personality view”—a very basic aspect of our conditioning.)

In my own consulting room, the process of inquiry unfolds in ordinary psychotherapeutic conversation. It develops both out of observations contributed by the patient and/or from creative or intuitive clinical ideas of my own. I may “invite” a patient to further investigate some particular aspect of their experience. I may suggest an “empirical experiment” to notice what feelings arise under certain circumstances, or I may just ask a pointed question that invites reflection. I may comment on something that seems to me to be happening in the Here and Now of the session and ask the patient to take a moment to see how he or she is actually feeling in that moment. I may introduce a clinical “pause” by inviting the patient to spend a few minutes getting a “felt sense”1 of what they are talking about. I may make an interpretation of some sort and ask the patient to notice whether or not it seems true to them, or I may invite them to investigate what evolves as life unfolds. When I work with meditators, I may sometimes “prescribe” a question for meditative investigation or inquiry: for example, “what is at stake here?” or “what aspect of yourself are you attached to here?” There are sometimes interesting comparisons to be made between daily life and meditation practice, and there may also be important points that bear upon the perspective of the dharma (whether or not Buddhist ideas are made an explicit focus).

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