Psychotherapy supervision: dealing with silence

I received this question about psychotherapy supervision from one of my Johns Hopkins graduate students. “In psychotherapy supervision, dealing with silence, is problematic for me. At least, that’s what my supervisor says. Can you help me understand what she means?” It happens in nearly every supervision at one time or another. You don’t understand your supervisor’s feedback. What should you do? 

My supervisor tells me that in talking with clients or patients, I don’t use enough transition statements. I have no idea what she means. So what steps can you take to find out about and address the problem?

I use this example because when a student posed it to me, I had no idea what the supervisor meant either. However, I had two thoughts. The first was related to the supervisor and the second is related to the issue of transition statements.

First of all, I’d encourage graduate students to clarify their supervisor’s feedback. Make sure that you understand what your supervisor means. What does she mean by “transition statements?” Can she give you some examples? Can you role play and practice with the supervisor so that you have a clear understanding of what she means?

Why are transition statements important? What is it that you are not doing with your patients/clients that she would like you to do? Asking your supervisor directly will (hopefully) do three things.

First, of all, you will know what she’s talking about and will be able to attempt to follow her suggestions. Second, you will establish the fact that you care about learning and care about doing a good job. Third, it will help your supervisor to be more explicit (which will enhance the learning experience for both of you!).

Now for the issue of transition statements. Let me try to articulate what I suspect is the problem. Then, I promise to give you some concrete suggestions that I guarantee will work (if I am correct about the problem).

I teach clinical interviewing and I have been providing psychotherapy supervision for many years.  I have no way of knowing what your supervisor meant but, I will try to guess. It has been my experience that new clinicians often feel tremendous pressure to fix their clients/patients. Rather, then looking the client in the eye and paying careful attention in communicating interest with an open body posture, and an empathic gaze, new therapists often try to jump in with advice.

Listening to patients is like wind sailing, a gust of wind comes along, your instinct is to lean back in an effort to counteract the wind.  If you do this, you fall on your derriere. In windsurfing, you need to do the counter-intuitive; lean into the wind and steer yourself.

Similarly, in clinical interviewing, the patient is distressed. As a therapist your instinct is to fix the problem. You jump in and provide solutions. Unfortunately, this isn’t helpful and it doesn’t work. Attempting to solve problems for patients is unhelpful because it conveys a lack of confidence in the patient’s ability to develop the requisite skills to solve his own problems. Helping a patient to understand themselves culminates in the patient generating their own solutions to their own problems. Thus, attentive listening promotes independence and autonomy.

In tandem with the instinct to fix the new therapist has the impulse to evaluate and analyze. Also, new therapists tend to want to dazzle their psychotherapy supervisors, colleagues and the patient. (Actually, I think that impulse persists throughout ones career. Just look at your supervisors :)).

In my experience, both as a student and a psychotherapy supervisor, this leads to too much questioning, of psychotherapy patients, and not enough listening. I suspect that what your supervisor is trying to address is your difficulty tolerating silence. If you fill silence you deprive the patient of the opportunity to articulate and explore their difficulties; this hampers growth. That is, filling in the silence gets in the way of allowing the patient to begin to take responsibility for themselves. Also, if you are talking and questioning then you are left doing a lot of guess work since you do not have a very good notion of what the patient’s problems are until they tell you.

Concrete suggestions

Practice the following things on your roommate, your mother or some other poor unsuspecting soul. (I guarantee that if you practice on your mother, without telling her, she will love it!) Better yet, practice them on your psychotherapy supervisor. Here’s how it works. You ask an open-ended question. With your client, it could be, “what brings you here today?”. With your mother, it could be “how are you today?”. With your supervisor it could be “what can I do to improve?”. You are in control of yourself. You are quiet. You look the person in the eyes. Your hands are at your sides; not across your chest. That is, you have an open posture. And you listen.

The patient says, “I don’t know.” Your mother says, “fine” and your supervisor says, “I don’t know. You’re just not very good at transitions.” Don’t despair. To your patient you say, “tell me about not knowing.” To your mother you say, “so tell me about that. What has been happening with you.” To your supervisor you say, “I suppose I’m not, but it is really important to me to become a skilled therapist.” Then, you wait attentively. If you really can’t tolerate the silence, count (to yourself) to 100. Unless you have an unusual psychotherapy supervisor, you will not have to wait that long, I promise.

Listen. Do not interrupt unless you actually do not hear a word. Just listen. Be quiet. Do not say anything. When the person pauses just wait or perhaps nod encouragingly. And wait. You’d be amazed at how long people will talk to you if they feel like you are listening. If they ask you your opinion about something just say that you would like to hear more about what they think about it and that you would like to know more about their feelings. If they persist, tell them that you are still formulating your thoughts but that you will share your thinking once you feel like you have a complete understanding of the situation.

Finally, the person will pause.  You will want to convey that you have listened and you have heard.  Also, you will want to test-out, “have you understood?” Here’s how you do it. You attempt in a sentence or two, to summarize what you think you have just heard. To your patient you say, “so what you are saying is that for you, it is very difficult to say why you’re coming here. You have a sense that something is wrong, but you can’t yet put your finger on just what it is.” For your Mom (well she’s the easy one)…. To your psychotherapy supervisor you say “so what you’re saying is, it would be really good if I could…”

This is called empathic reflection. It conveys that you have heard and that you want to understand. It gives the patient a chance to correct anything that they feel that you may not have understood. If you use this technique correctly, the person will continue talking and tell you more. Good luck. Please let me know how this works out.

Read about how to understand patient, or client, lateness and “no shows”.

And what about, when the psychotherapist is late?

Are you seeking psychotherapy supervision with me?

I provide psychotherapy supervision to licensed psychotherapists, psychoanalysts-in-training and graduate psychoanalysts. If you’d like to explore the possibility of working with me, feel free to call: 301.656.9650.

Looking for psychotherapy, or analysis with me? Feel free to reach out. Trying to find a psychologist in Washington DC; read this post.