In Therapy

A user's guide to psychotherapy

Eye Contact in Therapy, Part I

Mailbag: Why can't I look at my therapist?

My, what interesting carpet you have
The quickest way to make your comfortable face-to-face conversation awkward? Have an in-depth discussion about eye contact. Happens every time. Even in therapy.

I open the dusty mailbag once again to tackle a topic that appears to have reached epidemic proportions. Last summer I was bombarded with requests to discuss eye contact in therapy. Apparently, gazes are dropping at a staggering rate. Numerous disguised and distorted letters from unidentifiable and possibly fictional readers looked something like this:

I find it incredibly difficult to look my therapist in the eye. Why is this and what can I do about it?

The issue is quite common and appears in many forms. Some clients panic at the thought of looking their therapist in the eye, which is likely a problem outside the room as well (see support forums here and here). For others, eye avoidance is specific to the therapy office or to certain moments in session. It may be difficult to look up when talking about sex, for example. Either way, it's a problem that can cause the client to feel disconnected from the therapist and dread or even quit therapy. Therapy doesn't always make you feel better, but it's not supposed to make you feel more isolated. Why does this happen?

Let's review the fundamentals of eye contact. It's been known by mothers for millennia and by researchers for decades that a powerful developmental moment occurs when infant and mother (or primary caregiver) hold quiet, intimate eye contact with one another. It's understood to be a major part of attachment and bonding. A child staring into mom's eyes is solidifying the connection, receiving mirroring and building a feeling of safety and security. It's also intense. Even attention-loving infants must occasionally turn away from the intensity of eye contact to relax a little (see p. 13 of this article). From the very beginning we both crave and fear the power of this connection.

When age and experience add more self- and other-awareness, the stakes get even higher. The eyes send and receive so much information it can feel overwhelming. Parents want kids to look them in the eye to detect lies. We try to catch the eye of potential love interests. We get beat up for looking at someone the wrong way. Many would say that eye contact is where the terror and thrill of intimacy happens. For those who suffer deep guilt, shame or anxiety, eye contact feels dangerous—if you can see deep inside you'll certainly reject me.

Now take someone with any of these fears into therapy, where the custom is to sit facing one another and place the client's life under a microscope, focusing on the problems. Still wonder why some find eye contact in therapy challenging?

Unfortunately, it's difficult to find much theory or research on the topic. Psychotherapists are taught to note eye contact among many other behaviors when conducting an assessment, but statistics regarding when and how eye contact is made in session and what's considered "normal" are hard to find (except stuff like this). Perhaps a therapy researcher will find this post and share their treasure trove of fascinating, relevant articles.

Outside of therapy, we find plenty of studies and opinions on eye contact. As you might imagine, people with social anxiety, mood disorders and autism spectrum disorders are often challenged in this area. A recent study from British cognitive psychologist Dr. Peter Hills found that sad people tend to avoid eye contact while happy people actively seek it out. He suggests that there's a cycle here: avoiding eye contact leads to social isolation, which increases depression, which leads to poor eye contact.

I contacted Dr. Hills to get his perspective on the power and challenge of eye contact, and he was kind to share his thoughtful response:

At least in Western cultures, the eyes are the most useful visual feature. They provide cues for emotion, age and gaze (which is useful for shared communication, theory of mind, and learning). They also provide very diagnostic cues for identity. Due to the sheer volume of information that can be conveyed by the eyes, they are the most fixated upon visual feature and potentially it explains why (evolutionary speaking) they are in the middle of the face (in the vertical axis). The eyes are the windows to the soul and in this case it is because of the information they convey. Potentially, eyes are difficult to process because they convey so much information and cause cognitive overload. Alternatively, people may avoid eye-contact to avoid showing this information to people.

Interesting stuff. As is implied, the cultural norms for eye contact vary quite a bit. We Westerners expect and give plenty of direct eye contact, but worldwide it could be seen as disrespectful, flirtatious or even hostile. Making some eye contact may be the standard, but not everyone can do it. Even with their therapist.

Back to Fictional Reader's question about why it may be difficult to look a therapist in the eyes. Some possible root causes range from guilt, shame, anxiety, low self-esteem, shyness, past abuse, depression or autistic spectrum disorders to varying cultural norms and cognitive overload. To oversimplify: If the eyes are the window to the soul, and you don't feel particularly safe showing your soul, you'll draw the blinds.

All reasonable possibilities, but as a therapist I'm inclined to explore the client's experience of a symptom before casting my vote. I'd want to probe around with some questions. Why withhold your eyes? What was eye contact like in your family? What are you afraid might happen? Are you concerned about what you will see, or what your eyes will show? What do you gain by not making eye contact? What does looking into another's eyes mean to you? Was there a time when eye contact was comfortable? When did it change? What happened the last time you did look? What would it feel like to be seen, here with me now?

We're not done with this yet: Part II: What to do about it.

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Practice looking me in the eye at my facebook page or website.

Ryan Howes, Ph.D., is a clinical psychologist, writer, musician and professor at Fuller Graduate School of Psychology in Pasadena, California.

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