Interact Journal Integrative Ideas for the Process-Oriented Psychotherapist

Categories Supervision Dialogs

On presenting problems

I’m uncertain how to work with people who were abused as children, who have been in prison, are divorced, addicts, dying, have a history of . . ., a diagnosis of . . .

This client’s presenting problem is (fill in the blank). I can’t treat that. What do I know that would be of any help at all?

Psychotherapy is not about, “Something is wrong with that person so now we get to fix him.”

Psychotherapy is about inviting that person to be intimate with and aware of himself. Usually it isn’t the problem that’s the problem. Most of the time it’s the person’s relationship to the problem that is problematical.

Given that, here’s how I see myself working with “the problem.”
Th: So why are you here?
Clnt: I was abused as a child.
Th: Okay, so what’s your problem?
Clnt: My wife says our sex life is disappointing.
Th: Okay, so that’s her problem. What’s yours?

Here’s how I see it.
• First, there is his presenting problem.
• Then, there is the negative relationship he has with the problem.
• Then, there is the dysfunction which the negative relationship manifests into his everyday life.
• Then, there is the underlying trauma that led to the problem.
• Then, there is the original, and usually dysfunctional, underlying decision about Self which is acted-out again and again, with “the problem” as the stage on which the drama takes place.
• Underlying that is the unresolved existential issue which lead to the dysfunctional decision in the first place.
• And sometimes, particularly with addictions, the problem isn’t really a problem at all, but more of an attempt at a solution (self- medication, for example).
• So, let’s stop already, with the presenting- problem problem.

If someone comes to you wanting to change a particular behavior, thought-habit, or reaction which can be addressed by cognitive, hypnotic, or other behavioral means, and you are interested and willing to work that way, well, that makes sense to me. I employ those methods from time to time, but I won’t be discussing them here with any degree of expertise.

My natural interests, instincts, and probably neuroses, lie in another arena. My ultimate preference is to invite a person to explore his subconscious for the beginning of the problem, the root of the dysfunction, the primal scene during which he claimed the problem as his own. In psychotherapy, I’m looking to create an environment where the person can re-solve “the problem” to a different conclusion of:
• the relationship
• the dysfunction
• the trauma
• the decision about Self, and/or
• the existential or developmental conclusions which support the problem.

I’m wanting to fiddle with the dysfunctional decision about Self which was welded into place as a life-saving device sometime in early childhood and defaulted to, ever since.

I want to invite a person to access his Inner Learner, that child mind-state where “ah-Ha!” moments signal that the map of the Self has rearranged itself or that dendrite changes in the brain have added new learning to the adult brain. Check back here in a few years when neuro-psychologists have figured out how it all works.

As a professional, I’m not overly interested in a person’s psychological software, that library containing all the stuff he knows (cognitively) and can pass tests on and talk about.

I’m into the “knowing” that migrates back to the subconscious and adds itself to his psychological operating system – that reservoir of default beliefs such as “I’m okay; you’re not,” “I’m unworthy,” “If you have a problem, I have to, too,” and “My cup is always half empty,” etc.

So, from my point of view, one needs to understand virtually nothing about “the problem.”

Here’s an example. Say someone comes to you defining his problem thus:

He: I crave eating live grasshoppers for lunch.

You: So what’s your problem?

He: Well, this is the third girlfriend who has left me once she finds out I usually eat live grasshoppers for lunch. I don’t want to give up either the girls or the grasshoppers. Do you understand that this man’s problem isn’t about grasshoppers?


Without knowing anything else about him, we can guess that he is frustrated, lonely, grieving, and confused. Grasshoppers (or perhaps eating, or maybe lunches) are not The Problem. Grasshopper-eating is the stage (as in theater) on which he dramatizes his issues in the hopes of resolving them to a different conclusion. He probably also has a love-hate relationship both with girls and grasshoppers along with a certain resistance to consulting a medical professional as to a possible nutritional deficiency.

Frustration, loneliness, grief, love-hate relationships, and resistance? Piece of cake. You can work with those things. Those things are processes. Grasshoppers, girls, lunches, and health practitioners are just content and are useful only as props in his play.

No matter what the presenting problem, the symptoms, or the trauma, most people have the same fundamental issues. There are many ways to name these issues. I tend toward the existential, so my list includes:

• Permission to exist as is; permission to Be
– Shoulds
– Shame
– Self worth
– Permission to experience and allow the unfolding of Self

• Existential separation and aloneness
– Unclear boundaries

• Completion of developmental tasks
– Dependency issues
– Looking to externals for validation
– Control
– Taking responsibility for self

• Attachment issues
– Taking on vs. letting go
– Not always getting what I want

• Working through of trauma
– Redecision work about Self and Self’s interaction with the universe

• Inevitability of death
– Purpose

Additionally, all humans have the same psychotherapeutic challenges. They include
• Acknowledging and connecting with their experiences in the here and now
• Allowing themselves to move into and through impasses
• Learning new ways of being with others by honoring their true Self

So how do you explain this to the client who wants to know why you are not addressing the problem?

I’d invite him to keep the idea of “addressing the problem” in the forefront of his mind, no matter what I do. I’d remind him I am not a behaviorist, that I don’t intend to ignore the problem, but the way I work is to start with the problem and see where it leads us. I’d let him know that, in my view, the problem will change when the problem underlying the problem is resolved. Then, in the case of the grasshopper guy, I might say something such as,

“Let me show you. Get as comfortable as you can … and let your mind go back to (a time, the last time, the first time) you were about to have grasshoppers for lunch . . . Be there in that moment. See (hear, smell, taste) your surroundings. Be in your body. Look out through your own eyes. Experience your anticipation. Now push the “pause” button on this experience. Find the words for what you notice about yourself.”

Notice how I changed the tense of the verbs I used from past to present. I haven’t so much invited him back into a past situation as I have invited a past situation to be here in the present, here-now in this room. Also, I am inviting him to be himself, as opposed to watch himself. After that, I’d work with his response and go wherever he took himself.

Another idea: end each session by wondering out loud to the client how what he just did relates to his presenting issue. Let him decide.

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