A recent article in The Atlantic, “What Your Therapist Doesn’t Know” by Tony Rousmaniere, explored the use of feedback informed therapy (FIT) models and their effectiveness in increasing client outcomes. After reading the article, I wondered: Were my clients really doing as well as they reported? And were they leaving sessions thinking therapy was a healing or worthwhile experience? Clients have given positive feedback about therapy sessions and their therapeutic progress, but haven’t offered feedback on what isn’t working for them.
I’ve had this experience as a client in therapy. Some combination of kindness, socialized politeness, and expectation led me, at times, to leave sessions feeling disappointed, misunderstood, or frustrated without sharing these feelings with my therapist. I’m quite assertive and direct, so as I began to think about these questions around feedback, it struck me that if I hadn’t spoken up, it was almost certain that my clients were not giving feedback that might be important or even critical to our work and its effectiveness. In search of better ways to serve clients and facilitate the healing, change, insight, and discernment they sought, I decided to take on an experiment of my own.
The FIT models about which I read collect data through various forms of survey to be viewed by the clinician. Without a FIT model to utilize readily, I developed a trial of my own: Could I elicit more direct feedback from clients and more authentic responses during the session? More specifically, could I take time in session, at inflection points, to direct our attention to feedback on the process in the moment, and would this be perceived as useful or bear fruit for the client? In order to find these inflection points I decided to tune in more intentionally to micro changes in expression, affect, posture, body movement, gesture, and signs of autonomic arousal. And I paid greater attention to the cultural and relationship dynamics of socialization and power. I resolved to move towards these inflection points, even when uncomfortable. I also decided to track my own sensation more closely, paying attention to micro-signals that might indicate misattunement between my client and me. My practice changed – in ways that seem significant and meaningful.
I orient towards somatic modalities, but rather than tracking body sensation or noting a change in breath, for example, and assuming it was related principally to the presenting issue, I paused to ask whether or not some dynamic in our work was at play. Was politeness, or a desire to “be a good client,” or obligation to defer to me, or even a desire to not be “too messy,” at play? Clients resisted as I predicted. But I invited them explicitly to engage in a new level of honesty, drawing on the Japanese cultural practice of tatemae (“tah-tay-my”) and honne (“hoe-neh”) that I had learned living in Japan.
Tatemae, translated as built in front or façade, and honne, translated as true sound or true voice, capture the discrepancy between a person’s public persona and private truth. Honne appears, in my experience, to function as truth, both interpersonally and in policy and actions. Tatemae, in contrast, represents all of the constraint of socialization and cultural rules. Discussing these concepts seemed to give my clients greater insight into the kind of raw truth I thought might free them and increase the effectiveness of our work together, as well as their satisfaction with our therapeutic relationship. Sometimes clients pushed me to a kind of “insisting on paying the bill” dance. When they insisted everything was “fine” and I gave it another round of wrestling for the truth, though, many acquiesced to deeper truth: they didn’t find something useful; they needed more directness; they were struggling more than they had revealed; they could agree logically but at a body and belief level they couldn’t experience what I was pointing to. Clients allowed themselves more unhindered displays of affect.
Tom, who had a pattern of assuring me that he had fully internalized our work, admitted that he could “top down” the logic of healing but wasn’t actually there all the time, which gave him permission to be more honest, not only about when he was essentially over-functioning in therapy, but also about his struggles around being a man and what that means to him. We explored his beliefs around an obligation to over-function and to embrace extreme responsibility, and how he feels compelled to appear to be strong and in control at all times. This freedom, though challenging for him, allowed Tom to deepen our work and to experience that moving towards what he feared most–loss of control and abandonment–was where the richest healing might also take place.
Mark, whose presenting issue was debilitating anxiety, was always polite in session. We had worked together weekly for 18 months and until I invited him to dive into Honne I had never heard him express fully embodied anger. He had often expressed gratitude for the strides he had made towards resolving anxiety and increasing his functionality and agency. In the session in which I first explicitly challenged Mark he loudly and freely expressed his rage and pain at still struggling with anxiety.
Through welcoming the messy and welcoming criticism, my relationships and work with these and many other clients changed. Being intentional about seeking my blind spots, and paying attention to the factors that influence the therapeutic relationship, powerfully changed sessions and deepened the work I am able to do with clients.
Laura Lindekugel M.S., M.S.