In the following article, Dr. Paul shares the intimacies of the psychotherapeutic process with The Wall Street Journal’s Elizabeth Bernstein.
LIFE HEALTH BONDS
What Your Therapist Is Really Thinking
Yes, therapists sometimes get bored; excerpts from an interview with psychotherapist Paul Hokemeyer
Dr. Paul Hokemeyer, a psychotherapist, says ‘a large part of the value of psychotherapy comes from the thoughts that go through the patient’s mind in anticipation of the session.’ ENLARGE
Dr. Paul Hokemeyer, a psychotherapist, says ‘a large part of the value of psychotherapy comes from the thoughts that go through the patient’s mind in anticipation of the session.’ PHOTO: NICK DABAS
By ELIZABETH BERNSTEIN
Dec. 14, 2015 12:56 p.m. ET
Ever wonder what your therapist is thinking?
Paul Hokemeyer, a psychotherapist and licensed marriage and family therapist, discussed what goes through the mind of someone paid to help people with their most private problems. Dr. Hokemeyer specializes in relationships and treats people for issues such as anxiety, depression, narcissism, addiction and infidelity. He also serves as a senior clinical fellow for the Caron Treatment Centers, an inpatient facility in Pennsylvania and Florida.
Dr. Hokemeyer was a corporate bankruptcy lawyer for seven years before getting his Ph.D. in psychology. He uses several approaches in his practice including cognitive behavioral and dialectal therapies. He has private practices in New York and Telluride, Colo., a research office in Malibu, Calif., and also Skypes with patients. Here are edited excerpts from an interview with Dr. Hokemeyer.
WSJ: How long do you typically see someone?
Dr. Hokemeyer: One to two years. I don’t believe psychotherapy should be a lifelong endeavor.
How has your therapy style evolved?
When I first started, I was terrified of making a mistake and I made patients nervous. When I was in training a woman came to see me to deal with an abusive relationship. She sat terrified in a chair across from me, while I forced her to answer a series of rote questions. I should have thrown the questionnaire out and sat with her in the weight of her pain and talked. But I didn’t, and she never came back. I still get sad when I think about her, and I think about her often.
I’ve come to see psychotherapy as an art grounded in science. The art consists of connecting with a patient where he or she is, then using solid evidentiary methodologies and interventions to move the patient toward a reparative experience.
My brand of psychotherapy operates on a number of levels. The first requires me to be hyper-aware of the physical and emotional feelings the patient brings up in me. How do I feel in their presence? Am I anxious, bored, entertained, manipulated?
Then I focus on what they are saying, verbally and non-verbally. Do I feel the heaviness that comes from depression, yet the patient is saying everything is fine or trying to distract me with superficial details?
Once I have the data gleaned from our personal connection, I formulate clinical interventions.
What do you write down about a patient?
I find note taking during the session by a therapist to be rude. The goal is to be fully present for the patient. I jot down notes after the patient leaves to remind me of issues to discuss and insights made by the patient.
If the patient is being treated for depression and made his way out into the yard the past weekend to garden I would write that down and encourage the patient to continue. My files contain basic contact information, releases, an assortment of legally required forms and brief notes that indicate where we need to go and how we are doing.
What do you hope a patient will do between sessions?
A large part of the value of psychotherapy comes from the thoughts that go through the patient’s mind in anticipation of the session and when they leave. The goal is for the patient to internalize the reparative relationship with their clinician. This means that they hear their therapist’s voice and anticipate what their therapist would say when they are confronted with a real-life situation.
I love when patients make a confession about falling down on a commitment and tell me: “I know exactly what you’re going to say…” That means they are internalizing a nurturing, affirming voice.
I give homework when it is appropriate, but I tend to do the opposite of what a patient requests. The super-A types want lots of homework. This is a red flag. I don’t give it to them. Their homework is to sit with their emotions and feelings rather than intellectualizing them.
Some patients can be very treatment resistant. They say they want to change but don’t take action. These are the people I’ll assign homework to and discuss why they refuse to do it.
What is unhelpful for patients to do between sessions?
Beat themselves up. We all make mistakes in life. The key is to learn from them and move on. I tell my patients it is OK to look back at the past but don’t stare.
Is it helpful for patients to discuss their therapy with loved ones?
It depends. It can be helpful if you feel they have your best interest at heart.
What should patients do to prepare for a session?
Come into the room focused and motivated. Don’t come to me because you’re trying to get your spouse off your back or are more concerned with the text messages you’re receiving during our session.
What do you think about during a session?
I focus on the immediate, my feelings, thoughts, what the patient is saying, then step back and put it in a global context. Is what they are saying congruent with what I’m feeling? What patterns are emerging?
I also need to keep track of time, which is tricky. The last thing I want my patient to see me do is glance at the clock. I have three clocks in my office and I’ve taken to wearing an iWatch, but I still screw up.
Does your mind wander?
Frequently. Most of the time it wanders back to the session I had with the last patient and what I should have done differently.
It can also wander if the patient is avoiding connecting and filling the time with superfluous details. I’ll start to think about the dry cleaning or what I can have for dinner. This is important clinical data as it lets me know that just as I’m not feeling connected to the patient, the patient isn’t connected to me because they don’t feel safe enough to share the intimate details of their life.
Do you fire clients?
I will refer a patient out if I don’t feel we have a good connection or if their issue is outside of my scope of competence. I also refer out if I feel that our work is creating a financial strain on the patient.
Do you judge patients?
I’m constantly judging. It is my job. This notion of unconditional positive regard is a fantasy. Yes, I need to accept the patient for who they are, but to pretend that I won’t bring my humanness to the equation is unrealistic.
I need to know how and when to deliver my truth. The best example I can give is around issues of fees. Discussions around money are wonderful illuminators of personality. Typically, people who are miserly with money are miserly with emotions. People who throw money around have poor interpersonal boundaries.
Do you go to therapy?
I’ve been in individual and couples therapy off and on for 20 years. I started when I was practicing as a young lawyer, miserable and desperate to change my life. Recently, I’m focused on my marriage and so I’ve been investing in couple’s therapy.
I can be a very difficult consumer of psychological services. It takes me forever to find a therapist I trust.
What are your pet peeves?
I get annoyed when patients cancel at the last minute because of traffic or some other minor annoyance. This tends to be a chronic situation with the affluent. For them, what’s a few hundred dollars for the late cancellation? I view this issue as a clinical one and address it. I tell them it feels like they are hiding behind their money to avoid intimacy.
What if someone isn’t making progress?
Some patients love to play games. They are masters at manipulation and avoid connection at all costs. They will dominate the conversation with tales of great bravado, tales that illuminate their personality but keep us from connecting. I tell them to cut it out.
Do you dislike patients?
I dislike traits my patients display, but my job isn’t to like or dislike my patients. It is to give them a new way of relating.
My awareness of myself and my own issues enables me to relate to and feel compassion toward the vulnerability of being human. It is the thing we share and it gives us a strong foundation to build upon.
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