On Pushing, Pilling, Patting & Partnering

On Pushing, Pulling, Patting and Partnering

As a psychologist, I often find myself in the tricky space of balancing two therapeutic modes of being with a client: empathic holding on the one end, and challenging the client on the other end. As per classic Rogerian theory, I certainly subscribe to the idea that unconditional positive regard, warmth and empathy form the bottom line of any good therapeutic experience. After all, who would want to continue therapy if they do not feel understood, heard, and empathised with? (Certainly not me!) Simultaneously, I often remind myself that the time that the client spends with me should truly be of value to them, and give them something more than just a vent or a chat to a pal would have given them. Without being too fixated on the “fix”, I still want to aim to help my client feel something shift in a good direction. The challenge is to find the optimal space between absorbing empathetically (“patting the client’s back”) and “pushing and pulling” the client to change how they deal with what they are going through.

Maybe, for me, the answer lies in 4 anchoring points: (1) timing, (2) how challenges are framed linguistically, (3) a concept called (rather pompously) the “zone of proximal development”, and (4) overt collaboration with my clients on what they want to achieve.

With regards to timing, I believe the first priority in the beginning of therapy is to establish a strong therapeutic alliance. This will mean that in the first few sessions, while I am getting to know the client better, and building some sense of rapport and being on the same team, I will probably not lean into the “pushing and pulling mode” too much. After all, I don’t know the client and their circumstances and life stories too well in these early days, and it may be a bit presumptuous to dive into proposing changes and posing challenges too quickly. It may also be perceived as being dismissive towards the client, which is something I want to avoid at all cost.  As we move on through therapy and the client and I know each other better, it becomes easier to ask more challenging questions and look more deeply into what the client can do differently in the midst of their pain.

This leads to my second anchor point when placing myself on the continuum of “pushing, pulling and patting”. If I frame the challenge or change as advice, or as me telling the client what to do and what to change, then it may not work too well (at any point in therapy). There are numerous problems with this. It plays into the old power differential of the therapist-who-knows-best vs the-client-who-doesn’t-know-much, which is in no way directed towards the growth of the client. Moreover, it can lead to a sense of resistance in clients, where they shut themselves to healthier ways of doing things because the proposed change has been framed as advice, as superficially fixing the problem, or as a task handed down from someone in a position of power. Additionally, who knows if my advice would actually work? (Whenever I slip into advice giving mode in therapy, I usually diffuse it by making a joke about “the first rule of therapy is not to give advice… and for good reason!” and by having a laugh with my client about this dynamic.)

A much better way in my mind is to use the idea of curious exploration of different angles on the topic we are working on, rather than framing the work as “you should be doing things differently”. We bring in a playfulness, a sense of exploration or trying out different things, and observing with curiosity whether a new behaviour makes a difference or not.  In the ACT (Acceptance and Commitment Therapy) model, for example, this is an important part of introducing certain exercises, such as self-compassion or mindfulness activities. The therapist would say, “I am not sure if this will work for you, some people like it, some not so much… Would you be ok to try it out, and then we see what happens?” The stance is one of curiosity, interest, flexibility, and an acknowledgement of my own uncertainty. Let’s do a small case study.

Jeanine is a 55 year old woman who lives alone and who struggles with low mood in general, and anxiety about being judged negatively whenever she goes out. Unsurprisingly, this leads to isolation and a sense of meaninglessness in her life. An attempt at a behavioural intervention to help Jeanine take small positive steps could look like this:

Therapist: I can see that you feel very stuck – both physically at your home, but also mentally in terms of being lonely and isolated. There is no “one-size-fits-all” answer to fix this, but there are a few things we can think about and try out that may help even just a tiny bit. Some of the things we try may not be for you, and that’s ok. Some others may be really helpful, even if we anticipate that they might not help. Would it be ok for you to give it a go, just as a type of experiment to see what helps you take a step towards the life that you’d prefer for yourself?  (The therapist then moves into discussing things like opening windows and curtains, taking a short walk, saying hello to a neighbour, etc.)

The third pointer to find a balance between “pushing” and “patting” is Lev Vygotsky’s so-called “zone of proximal development”. This concept is probably more widely known in educational circles, where it refers to the difference between what a learner can do without help (i.e. independently) and what he/she can learn to do when guided by a skilful partner or teacher. This is also called “scaffolding”- indicating that we cannot expect a learner to make big jumps, but rather learn step by step, with the teacher gradually increasing the difficulty of the task in small and appropriate increments (“building the scaffolding to climb higher”). The same thing goes for our work in therapy, especially when we are working with a client who is quite stuck in unhelpful thoughts and behavioural patterns. We cannot ask someone to do that which is impossible for them. We also should not only ask of a client that which already is easy for them. We should try and pinpoint a task that is a bit of a stretch, but not an unfair and impossible challenge.

Especially when working with a person who struggles with anxiety I would use the idea of scaffolding very often, usually in the form of a rather classic “hierarchy of anxiety”, quantifying on a scale of 1-10 how hard certain tasks would be (with 1 being a little bit anxiety-provoking, and 10 being the worst anxiety imaginable). Let’s say John has been in a car crash, and now is mortally afraid of driving again. He wants to drive again, as he equates that with freedom and independence, but it simply seems like too hard a task. John feels like he freezes up even when he just thinks of driving again.  The hierarchy for John might look something like this (created by him and the therapist together):

Task/ Challenge Rating/10
Driving on the freeway 9
Driving around in the neighbourhood 8
Driving to the local shops, 1km from his home 7
Travelling as passenger in the front seat next to the driver 7
Travelling as a passenger in the back seat of a friend’s car 6
Starting the car, but not driving anywhere 3
Sitting in the driver’s seat while the car is parked 2
Sitting in the passenger seat while the car is parked 1

Of course, we will start at the bottom of the list with the things that cause the least distress! This is called systematic desensitization – basically just another word for scaffolding, or working in the zone of proximal development. By taking small steps, we gently retrain the mind to feel safer, and to gain confidence bit by bit.

A fairly out-dated alternative strategy for treating anxiety is called “flooding” – this is where we skip all the scaffolding steps and push the client into the activity that revs up their fear to a 9 or 10 out of 10. For John, that would be to force him to drive on the freeway immediately, hoping that he will swim rather than sink. Nowadays that would be a bit controversial, as we place so much emphasis on collaborative decision-making in the therapeutic process. In other words, don’t try and be Professor Gallagher from Gary Larson’s wonderful world of The Far Side!

Professor Gallagher | The Far Side!

Fourthly, when positioning myself in a place from where I can help clients propel themselves forward in a meaningful way, I need some open talk and overt collaboration about the client’s goals. This is our guiding light for therapy: what does the client want to get out of this? And are they willing to take some risks or try new things out in order to get there?  I sometimes compare deep psychological work in the therapeutic hour to going to the physiotherapist when you are struggling with muscle pain in your back. We usually expect the physio session to be at least a little bit painful or uncomfortable. In fact, we’d be quite surprised if the physiotherapist would give us a tickle and a nice back scratch and send us on our merry way. Sure – it would be “nice”. But would it be helpful, or make the muscle ache go away in the long run? Probably not. Intuitively, we know that we will not make gains without some form of physical effort or challenge.

Similarly, in the therapy hour, we work hard. There is effort, and attention and focus and risk-taking. There is an honest turning of the gaze inward; we take stock and feel and think and formulate. The therapy hour is more than a mere feel-good chat, and will hopefully have more valuable long-term positive effects than just the pure short-term cathartic relief that comes with a good rant or vent.

Along the same lines, the client also has to know that much of the work that will help them move forward, is done outside of the therapy hour. I sometimes facetiously say goodbye to a client at the end of their session with the words “Now is when the real therapy starts – the moment you walk out of the door!” If the client understands from the start that good therapy means taking risks inside and outside of the therapy hour, the stage is set for me as a therapist to regularly check in with my client on how we are tracking in moving towards the goals they stated they wanted to accomplish. This will also help me to introduce tasks and challenges that fit in well with the client’s explicitly stated goals without feeling that I am imposing or pushing and pulling them. Open discussion and overt collaboration on the “how” of change is often incredibly helpful in this regard. 

Maybe, after writing all of this, I sense that I may need to find a new metaphor. Maybe I need not think of positioning myself somewhere on the continuum of pushing, pulling, and doing back patting. Maybe it sits better with me to have an image of the client and I walking alongside each other, in the direction of some form of healing and growth. At times, we would have to pause that I can “pat their back” with empathy, just containing and validating whatever they are feeling. And at times, I may take the lead and suggest certain new and interesting-looking (or scary-looking!) paths and avenues. At other times, I will be the one is who is being led by the client: hanging back and looking on with admiration when my travel-partner is able to simultaneously “pat” and “push” themselves, and choose courageous new ways of moving forward. The lines of distinction between pushing, pulling and patting become beautifully blurred when partnering becomes the golden thread connecting them all.

Bon Voyage!

Lindie Oppermann
Felix & Sage Psychology

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