How Therapy Works (2): The Power of Small ‘A-ha’ Moments

Insight doesn't need to be ‘deep’ to be useful.

Posted May 10, 2018

An old Zen tale has a master and a student sitting on the grass to eat lunch. Suddenly, a grasshopper flies by. Without looking, the master raises his hand in a swift motion and catches the insect mid-flight.

            “How can you do that?” asks the astonished student.

            “How can you not?” replies the master.

We all have areas of expertise where complicated things have become easy, inevitable, and obvious. Once we become fluent in the language of our realm of expertise, we tend to forget that to the uninitiated, things look much different, like a foreign language sounds to the tourist. I’m often reminded of this when I interact with some exasperated IT person, who’s baffled by my inability to click my way out of a computer jam, a process that looks utterly intuitive to her.  In a similar vein, psychologists often experience situations in which some minor insight that is quite self-evident to us delivers a surprising and fresh, sometimes revelatory, ‘a-ha’ moment for the client. Here are a few examples:

1. Client A, an ambitious middle manager, is seething with anger, filled with rage and revenge fantasies aimed at his boss, because the boss is too old-school and hands-on for his liking and insists on overseeing all assignments before giving final approval. When I inquire about other times in the client’s life when he’s experienced this kind of anger, he has no difficulty providing examples. He remembers raging at his father for grounding him as a child every time he failed to obtain excellent grades. He remembers raging at a girl he’d fallen for in college, because she chose another man over him. He remembers raging at the thief who stole his bicycle from his garage one night. And so on.

            “So all these instances provoked a similar response: rage and a desire for revenge?”

            “Right”

            “And yet they are very different.”

            “How do you mean?”

            “Your boss has habits that happen to annoy you; your father, in his mind, was trying to help you succeed; the woman fell in love with someone other than you; the thief knowingly took something that was rightly yours.”

            “They all hurt me the same.”

            “But that’s not the whole story.”

            “Meaning?”

            “Well, if someone hit me with their car and injured me, I’d want to know if they did it on purpose or by mistake. Yes, both ways I’m injured. If they hit me intentionally, I’d be mad. But if it happened by accident and they now felt terribly guilty and ashamed, I might actually feel bad for them.”

            A-ha.

            I continue: “Imagine two circumstances where someone’s hand makes contact with your shoulder and you experience a sharp pain. In one scenario, the person has just punched you hard, intentionally. In another, their hand inadvertently touched a fresh bruise under your skin. While the pain might be similar in both cases, each warrants a different response.”

Upon reflection, the client realizes that his emotional response repertoire is underdeveloped; too rigid, narrow, and undifferentiated to serve him well in his commerce with the world. He stands to benefit from learning to distinguish between pain caused intentionally and directed at him personally, and pain caused inadvertently or generically. A person is ill-advised to take the whole world as a personal affront. From the point of view of mental health, it’s always useful to ask: Am I in pain because I’ve been hit, or because someone inadvertently brushed against my bruise? The fact you feel attacked does not mean someone is attacking you.

2. E/RP is a common and rather effective treatment for OCD. This approach involves triggering the client’s ruminative discomfort (Exposure) while preventing them from performing their comforting compulsive rituals (Response Prevention). In this way the client learns that they can handle the discomfort of their obsessive concerns (such as contamination) without having to avoid it by resorting to their dysfunctional rituals (excessive hand washing). E/RP can be practiced under a therapist’s supervision in session and ‘in vivo,’ in the world. Later in treatment, the client is assigned ERP tasks to perform on their own.

The OCD Client B tells me of one such instant. She was seated at a table that was near the restaurant’s restroom door. People going in and out of the bathroom were passing close behind her, thus provoking her contamination fears. When I inquire about her thoughts during this episode, she confesses feeling angry and upset at these people, for passing so close to her on their on way to restroom.

            “So you’re mad at the people who pass behind you.”

            “Yes.”

            “Let’s consider this. Have these people done anything inconsiderate, immoral, or aimed at hurting you?

            “No, they’re just going about their business.”

            “As you would like to be able to do.”

            “Right.”

            “So, do these people really deserve your anger?”

            She hesitates, and then: “No, they don’t.”

            “What does, then?”

            Pause. A-ha.

            “The OCD.”

This is a common feature of many mental health problems. Like so many a populist politician, disorders present themselves as allies, pointing to some other enemy to distract attention from their true corrupt nature. Psychological disorders represent a type of false consciousness, wherein the real enemy evades detection by assigning the ‘enemy’ label to innocent others. People with eating disorders often see food as an enemy, a source of trouble and danger and pain, and see the eating disorder as their ally, their source of control, strength, and hope. Addicts become aligned with their substance of addiction, and resent whoever is attempting to limit their access to it. Anxious clients come to regard their anxious avoidance as a protective solution, rather than the problem.

In fact, the people around you going about their business without preoccupying themselves with fears of contamination and compulsive cleaning are the solution, as their habits and responses are reasonable and adaptive. Food is the solution, as you need it to survive and be healthy. Sobriety is the solution, as it allows you to face your challenges, and learn how to manage stress effectively. Feeling anxiety by facing your fear is the solution, allowing you to habituate, and to learn proper fear management. Therapy can help clients change their allegiances, and come to experience their disorder as their foe, not their ally, and its admonitions as propaganda rather than truth, noise rather than signal.

3. Client C, a grad student, has a tendency to devalue herself and catastrophize challenging scenarios in her life. I note that it appears she’s adopted a biased habit of mind, whereby she rushes to practice self-criticism and predict calamity prematurely. “It’s like you volunteer to do prison time before committing any crime,” I say. The alternative, I propose, is to learn a fairer, more constructive self-appraisal procedure. I ask her for an example of a current anxiety. She says she’s super anxious about an important exam coming up. I use the ‘so what?’ technique to track her anxiety to its source.

            “When you feel anxious about the test, what are you telling yourself?”

            “I’ll fail the exam.”

            “So what? Let’s assume you fail. What then?”

            “I’ll consequently fail college.”

            “So what?”

            “I won’t find job.”

            “So?”

            “I’ll and end up alone on the street.”

            “So?”

            “I’ll starve and die there.”

I then suggest we examine this line of thinking, looking at each prediction and asking how likely and how bad it is, in fact. Given average passing rates and your own record, how likely are you to fail the test? Given what you know about college life, how bad is it really to fail one test? How common it is for a failed college test to lead to homelessness and death? Etc. She acknowledges that the catastrophic scenario is a low probability. Not a bet she would stake her house on. She experiences momentary relief. I recommend that she apply the technique whenever a troubling scenario appears in her head. Then, she says:

            “But if I begin to think more positively, I will begin to cut corners, tell myself rosy lies, make nice predictions to feel better, and then I’ll stop working hard, and I’ll end up failing…”

            I stop her and say, “You’re doing it again”

            “Doing what?”

            “Your thing.”

            Pause. Then, the ‘a-ha’ moment:

            “Oh, showing up at prison.”

The client realizes she is repeating her core pattern of self-devaluation by rushing to assume she’ll misuse her new coping tool. To paraphrase Maslow, if your only self-evaluation tool is a hammer, you will beat yourself up for anything.

4. Client D is a tightly wound middle aged man driven to succeed in business and prove himself worthy to his wife and father, both of whom are highly critical of him. He has a tendency to make detailed plans he doesn’t keep, which makes him feel guilty; he has expectations about what success means that, because he can’t meet them, contribute to his feelings of guilt. The client thinks that his constant guilt is a byproduct of his failure to complete his success-oriented plans and goals.

            “My goal in making these plans is to succeed in life, and the guilt tells me that I’m failing.”

            “The guilt is an unfortunate byproduct of your failure to carry out your plans for success.”

            “Yes.”

            “So your plans for success keep failing.”

            “Yes.”

            “And yet you keep making them.”

            “Right.”

            “So perhaps they are not plans for success, but plans for failure.”

            “How do you mean?”

            “Let’s take an example: When a child keeps misbehaving despite his mother yelling at him to stop, we suspect what?”

            “That he’s getting something out of it.”

            “But all he’s getting is yelled at.”

            “Maybe that’s what he wants.”

            “Because?”

            “It’s attention. He’s getting attention.”

            “So the child is not misbehaving despite being yelled at. He’s misbehaving in order to get yelled at.”

            A-ha.

When a behavior repeats despite seemingly punishing consequences, it is useful to ask whether the punishing consequences are the behavior’s actual aim. In other words, when your attempts at success bring about repeated failure—particularly if that failure is at your own hands—then perhaps you are actually attempting to fail.

Why would one attempt to fail? Perhaps it’s what you feel you deserve. We often treat ourselves—and have others treat us—not as we wish to be treated, but as we believe we deserve to be treated. If someone internalizes a notion of themselves as inadequate (a message received, say, from a harshly critical parent), than a sense of failure becomes integrated into their sense of self, and they may believe that failure is their deserving lot. They cannot feel truly at home and truly themselves unless they experience failure. Success, on the other hand, is a foreign land, an unknown language.

On the psychological level, home is a subjective experience; it’s where you feel at home, not where you are objectively safer, or more well-loved, or thriving. Stallone’s Rambo goes back to the jungles of Vietnam because, “what you call hell, he calls home.” For many people, therapy is akin to an act of emigration: a difficult process of leaving home under duress and having to adopt a new culture, a new language, and new habits, to make a new home.

5. Client E, diagnosed with social anxiety, is isolating herself by avoiding social contact and activity. When asked to explain the purpose of this avoidance, she explains that she’s afraid of negative interactions, which in her mind will lead to rejection, which in turn will lead to isolation, which in turn will lead to loneliness. So instead, she stays home.

I reflect to her: “So, the reason you fear social rejection is that it will cause you to end up alone, and lonely.”

            “Yes.”

            “So, instead, you stay home alone.”

            “Yes.”

            “And how does that feel?”

            “Lonely.”

             “So in effect you have prescribed the disease as your cure. You’re afraid that if you show up for the game, you may lose, so you forfeit, assuring a loss.”

            A-ha.

            “That doesn’t make much sense,” she says.

            “Right. You know, if you play, you might win; particularly if you practice and improve your skills first. And this is what therapy can do...”

This is a dynamic commonly seen in psychotherapy. Clients defend against the possibility of loss by making it certain. The client fears getting hurt if they become intimate with someone, so they distance themselves, thus practically guaranteeing they’ll arrive precisely at the place from which they were running away. We are all loss-averse, particularly when the stakes concern a loss of social status or self esteem. Yet life will inevitably involve loss, and the appropriate response to this fact is to improve one’s competence (to maximize the odds of a win) and one’s skill at managing disappointment (to minimize the impact of a loss).

6. Client F, a young city professional, is afraid of dogs, having been bitten by one as a child. In the intervening years since that attack, she had been studiously avoiding contact with dogs. Recently while looking for an apartment, she found a nice place near her downtown job. The location is great; the rent is a bargain. The only problem is that the owner of the place, who lives on the ground floor, has two dogs.  The client is terrified at the thought of sharing such close quarters daily with the feared creatures, but is loath to lose the housing opportunity, and is under time pressure to decide.

When I ask her to tell me about the origin of her fear of dogs, she relates the attack episode in detail, along with the terror it provoked.

            “So this initial attack provoked fear.” I say.

            “Yes.”

            “And the fear led to avoidance.”

            “Naturally.”

            “So, you’ve been avoiding because of the fear.”

            “Yes.”

            “Yet you’re clearly still afraid.”

            “Yes.”

            “Even though the dog that attacked you is no longer around, the attack is over, and you’re no longer a child. The fear persists”

            “Yes.”

            “So the original attack initiated the fear, but it is not what maintains it, since the attack has stopped, and the fear persists.”

            “Yes.”

            “So what’s maintaining your fear?”

            “The memory of the attack.”

            “And what maintains the predominance of this memory over all other possible dog-related memories, which could involve fun, rewarding, and safe interactions with dogs?”

            “There are no other dog-related memories.”

            “How come?”

            “Well, because I’ve been avoiding dogs.”

            “Right. In other words, you are afraid of dogs because you’ve been avoiding them.”

            A-ha.

Anxious people often tell themselves that their fears lead to avoidance, which is true in the short term. But in the long term, avoidance maintains and strengthens the fear, in part because it prevents new corrective and relevant experiences with the feared object or situation from occurring. To get over a fence, you need to approach the fence, engage it, and figure out how to negotiate the challenge it presents. Same with fear.

She decided to take the apartment, and face her fear of dogs. Looked at right, it’s a twofer.

The above examples constitute a few tidy snippets out of the more arduous and messy process of real change. Every clinical interaction is of course open to multiple interpretations that may or may not prove useful for the client. As a rule, helpful interpretations and insights need to be rooted in scientific knowledge and knowledge of the client. The client must also find these insights resonant, reasonable, and actionable in their world. To move people, your story needs to be not just true, but also good. Moreover, new awareness is only the beginning of the change process. In order for change to actually occur, new awareness must be repeatedly reinforced, and the new insights must lead to new social and individual behaviors, which will in turn help shift a person’s emotional architecture in the direction of health.