There are several goals in psychotherapy. We seek to "find the Other," to confirm for and develop in the patient a presence, to manage the various social forces that impinge on the patient’s life from inside and out, and to resolve (and in some cases, also to create) conflicts.

Implicit in therapy is a normative view of being human, or the human Being, which includes the capacity to be alone with another, self-possession or personal freedom to be oneself, and a liberation from the need either to invade another or to be invaded.

Two schools of psychology are particularly concerned with language in the practice of therapy. These are the object-relations and existential schools. Object-relations theory is that branch of psychoanalysis that relates failures in development to failures in the social environment of the patient. It takes an environmental viewpoint, and has served to widen psychiatric understanding. Existential psychiatry, especially as practiced by D.W. Winnicott and Heinz Kohut, has trespassed on psychoanalysis with a focus on the place of values, ideals, authenticity and selfhood in sickness and health.

A further prefatory remark should be added that real therapy is by no means linear, and although the arguments that follow are developed in a linear fashion, the endeavor, when actually practiced, is full of overlaps, twists and turns.

Therapeutic settings can manifest three forms of absence. There are those patients who remain hidden for protection from invasive others. These patients often have no individuality of their own, earlier in life having taken up an existence modeled on that of others. The fundamental problem here is one of isolation, and empathic language can put the therapist with these people.

Then there are those patients who don’t stay present. They disappear into others, and are often detected only by their effects on us. An example here is the "good patient," so adept at pleasing others that the most subtle cues from the therapist will elicit obedient behavior. The problem here is a past history of domination, and interpersonal language will help here to achieve a working distant between the therapist and patient.

The third type is the supine patient, who is hardly present at all. This patient has no independent existence at all, due to a lifetime of harsh criticism and his own internalized self-critical voice. The problem here is essentially one of submission, and the appropriate language is performative, to help liberate and develop the individual.

While different types of patients warrant different types of language, the various schools within psychiatry have their usual types of language. For example, mainstream psychiatry (operating in the medical model) will use interrogation: asking the patient questions about his behavior. Psychiatry practiced from an existential perspective will use rhetorical empathic language, to enter the other’s world, to see the world from the patient’s eyes, to share the burdens and joys of the patient’s realm. Its language is affective, stressing the heart and soul. Freudian approaches rely mostly on explanatory language, using the head (rational). Interpersonal psychiatry that tries to manipulate the therapy to provide "good management" relies on the hand.

Human disguises against predation produce various types of psychological distortions. We see the "good" patient, docile, so adept at discovering expectations that he becomes a mirror of the therapist’s wishes. Then there is the narcissist, who is marginally present, holding his central energies inside, able to reach only a little beyond himself. The most difficult is the patient who keeps his mind from the therapist, or has perhaps lost it altogether. The real self, in this case, is hard to find.

The most certain way to find these patients is through the ability to empathize with them. Empathy is the capacity to participate in or experience another’s sensations, feelings, thoughts or movements. These are the data of empathic work.

Empathy can be active or passive. In active empathy one searches out the other, using intuition to sense what the other is feeling, and then expressing it either verbally or with congruent body language (e.g. gesturing). Even catatonic patients can be reached this way.

Passive empathy takes a waiting sentient attitude. The therapist echoes the patient’s statements, supports and reflects his emotions. One form of such empathy is Carl Rogers’s nondirective or client-centered therapy.

Empathy is essential in the therapeutic encounter, for without it, the therapist cannot achieve sufficient closeness to aid the patient. For example, when working with a depressed patient, if the therapist does not feel depressed himself, it is a sign of lack of empathy: He is not close enough to the patient to help him. Psychotherapeutic work moves through an underworld of strong emotional tones that move and shape the therapist during the course of the session. He has to grasp these forces and turn them to clinical advantage if the patient is to be helped.

There are three types of empathy: affective, cognitive and perceptual. Affective empathy focuses on feelings, as observed in verbal expressions, tone of voice, posture, content of speech. Sadness, for example, is revealed in talk of depreciation, regret and despair; anger, in venting; and flatness (no affect), in speech without definable content, that wanders, is fragmented and hard to remember.

Cognitive empathy matches the two minds: The therapist finds himself inwardly completing the patient’s sentences. The closer the match between what he expects and what is said, the closer the empathic cognitive connection.

Perceptual empathy is a seeing of the patient without the habitual baggage of perception. This is a seeing with fresh eyes. The patient appears as a new person, producing a sense of surprise in the therapist. This form of empathy frees the patient to change, because he is perceived in a new way.

None of these forms of empathy is easy when the patient hides or is an "impostor." To sense when this is the case, the therapist must use himself as an instrument of testing, relying on his own affects, sense of closeness and movement.

Finding the other also includes time and space, and helping the patient to relate to a world of particular time and place. Space disorders, e.g. a fear of heights, are very commonly encountered in psychotherapy. Likewise, a feeling of rootedness goes a long way to providing the patient with the experience of connectedness.

Finding the other can also require "imagining the real," to use Martin Buber’s phrase. This is a process of using one’s imagination to connect with the real person behind the false front or catatonia. The therapist comes up with an hypothesis of who the patient is, which then must be tested for correctness. This is done via an exploration of the patient’s world, a process that often begins with imitative statements.

Therapists use imitative statements to indicate to the patient that the therapist is with him. Such statements are particularly useful with patients who both need someone and find it difficult to have anyone close. The goal here is to comfort without startling, so the initial imitative statements are bland, that is, they do not force the patient to feel what they think the therapist wants them to feel. Such blandness is particularly important with patients who do not possess themselves. They may have had parents who "owned" them, or they grew up having to withdraw from invasion or possession. The neutral empathy in imitative statements helps the patient strike a balance between being connected and self-protective.

Imitative statements initially may have to be expressed passionately, in order to be shared and spoken for the patient. Over time, the passion is gradually reduced, as the patient becomes able to accept the feelings. For example, with a patient who seemed especially still and distant, the therapist mused aloud, "What is one supposed to do?" This the elicited a response from the patient, who heard her confusion articulately and resonated to the close imitation of her affect.

This form of therapeutic language is more aggressive than imitative statements, but, like them, is expressed through impersonality and rhetoric. These statements are usually directed at states of mind, and are perceived by the patient as non-invasive (assuming the empathy is accurate, i.e. that the therapist is sensing the patient’s feelings, rather than his own).

Most of the time simple empathic statements are exclamations: short, emotional utterances that acknowledge the patient’s feeling state and seek to share that state. Examples include "How awful!" "Frightening!" They can also be statements of objective description: "Anyone would feel..." In their simplest form, they are non-verbal: snorts, "uh-huh."

The key to the successful use of simple empathic statements is spontaneity. When expressed spontaneously, they reflect the therapist’s genuine feeling resonance. Used deliberately, for effect, they come across as contrived, and actually widen the personal distance between therapist and patient, precisely the opposite of the hoped-for result.

When simple empathic statements are full sentences, they are called translations. These refer to states of mind that are seen as universal or readily understandable, and they serve to validate the patient’s emotions by accepting them as the therapist’s own. In a typical example, the patient is discussing some very distressing experience, and the therapist responds, "I feel terrified when I realize what you are experiencing." Both therapist and patient then are subordinated to the feeling they share.

Such empathic language offsets the power of resistances and can direct the patient’s material past them. When the empathic flow between patient and therapist is strong the patient can often encounter a memory heretofore forbidden to consciousness. Defenses, likewise, can be breached.

These more complex forms of empathic language have the same impersonal and exclamatory elements as in empathic translations, but also have something more. They enable the therapist to deal with the mass of contradictory feelings or situations that the therapist does not understand. The key to successful use of these statements is not verbal skill, but genuine feeling by the therapist. If a powerful empathy is present, it can overcome unpolished language. With the intent to attune oneself to the patient, the means (words) follows.

Complex empathic statements can be illustrated with three key phrases:

"No one understands." This is the most preliminary empathic statement, suitable for use with those patients whose background, appearance or personality makes them particularly difficult to understand.

"No wonder!" The therapist here places himself between the emotion and whatever precipitated it, connecting the two. The implication to the patient is, "In view of what happened, it is natural to feel..." (whatever emotion the patient revealed). This is, in effect, a denial of the patient’s denial of feeling. The empathic statement here produces a reconnection to the forbidden feeling, made possible by the patient finally being in a place where he need not face the unacceptable alone. This exclamation introduces the state of wonder and shows the patient where the therapist is, removing the need for denial. The patient can feel free and safe in admitting to have the feeling.

"God knows...!"/"God forbid...!" This statement is used to bridge conflicting statements, and is a useful technique when dealing with dissociated behavior. The point here is to bring into being a "provisional government" within the patient with which the therapist can work. Bridging statements like this are the verbal material that establishes such a representative body when a patient lacks a sense of self sufficient to do so himself. Such a technique is especially important when dealing with imprisoned patients, for those with no history. In these cases, the therapist must build the provisional government entirely by himself. Bridging statements then begin to bring together the patient’s separated parts. In time, the provisional government becomes established in the patient.

Complex empathic statements like these are effective because they acknowledge the conflict the patient feels, and they assume the patient’s behavior serves sensible ends. In effect, these statements reverse a reversal, or, more formally, they correct a reaction formation, bridging discordant elements. In this way, the patient takes first steps toward integration.

Simple empathic statements (translations) and complex empathic statements (bridging statements) put the therapist within the patient’s experience. Extensions permit movement through that experience. For example, a state of mind or affect is extended through time, with an additional phrase: "It has been difficult for a long time."

This begins to explore the patient’s experience, and must be done carefully so the patient does not feel invaded. Note that this process of exploration does not use questions. Questioning—interrogation—encourages the very thing therapy is trying to avoid, i.e. the widening of the subject-object distance. The suffering patient who feels alone in his despair needs precisely the opposite of greater distance from the therapist.

Extensions can include not only time phrases, but extensions of feelings, space and drives. For example, "There hadn’t been many feelings there before." Such sentences help to locate the patient’s experience to provide a structure for remembering. They help to bring material up from the unconscious. Meanwhile, they help the therapist to enter into, understand and share the world of the patient, to see the scattered elements of the patient’s life, and how they might form an integrated person.

Causal extensions are ways to ask "why," without putting the patient on the defensive. These begin with an assumption of an understandable human reason for the patient’s behavior, e.g. "You must have had some good reason for not calling." Note the avoidance of the more usual "Why didn’t you call?" Such questions about causes put the patient on the defensive, and can intensify shame, and serve to widen the separation further. The whole point with the use of extensions is to share what the patient bears heavily, so as to lighten the load and to understand his existence.

Empathic statements and extensions address isolation. "Good management" is a version of another type of therapeutic language: interpersonal speech. This type addresses domination. It is the verbal instrument to manage distance, to deflect the invasive patient, or to reduce the patient’s fears of being invaded. Interpersonal forms of speech puts the therapist’s utterances in a form that the patient feels free to take or leave.

Good management is essential because the therapist cannot work without some distance on the patient’s suffering: if the patient’s mind has invaded the therapist’s, he can’t function. The goal is to establish a working distance between patient and therapist, such that they can be alone together.

Good management is useful when dealing with power issues. Use empathy first to find the patient, then switch to interpersonal speech to defend the patient against overpowering forces, or to defend the therapist and patient against each other. A balance of power needs to be maintained between therapist and patient, so neither overwhelms the other.

The rule here is to clear the clinical field from the direction of the patient, so as to provide him with a fresh experience of the therapist. The therapist does this by regarding everything the patient presents as a fiction, or an artifact of the social world. In this, he is recognizing the fact that psychological cognition—the determination of psychological facts—is very hard and easily contaminated by the therapist and patient.

It also is a recognition that therapy requires attitudes sharply opposed to each other: On one hand, therapy requires empathy, i.e. credulity operationalized, whose goal is to be taken in. On the other hand, therapy requires interpersonal statements, i.e. skepticism operationalized, whose goal is to prevent the patient from projecting on to the therapist. The aim behind all this is to liberate the patient into the new, to open the struggle for human existence to fresh lines of thought.

When using interpersonal language, we need to observe patient movement. If the patient is moving away, the eyes become vacant or distracted; the voice fades; the content of speech becomes disconnected. If the patient is moving toward the therapist, the eyes yearn or show anger; the voice is eager; and the therapist may feel crowded. Generally, in observing patient movement, the eyes and voice will be more revealing than the face and body movement. With some patients, e.g. narcissists, there may be little discernible movement. Even their presence may be hard to find. In these states of extreme self-centeredness, the degree to which the patient is present can be gauged by the amount of disruption necessary by the therapist to catch the patient’s attention.

Establishing a working distance in therapy requires both parties to acknowledge and respect the presence of the other. Empathy is possible only when we manage distance, not when we are overrun or faced with an absent patient.

Projective statements are declarative statements that evoke. "It was a nice day in August." is one example. Such statements serve to direct the patient’s attention away from the clinical relationship, and to reduce the patient’s projections on the therapist. The patient turns to the subject of the projective statement and is stimulated to add, correct or erase the thought. The patient is set in motion as naturally and richly as possible.

Projective statements require an environment of balanced power and authority, for they have a democratizing and equalizing effect on the therapeutic relationship. The authority of the therapist should not substitute for the freedom of the patient. Likewise, the authority of the therapist cannot disappear, since the patient (particularly the demoralized one) needs the security of knowing there’s a therapist in charge.

The "authority" of the therapist is not meant to imply he is always correct or final in his judgments. We are wrong far too often in psychotherapy to have such attitudes. But the therapist recognizes the great power he has in a willingness to be wrong. This willingness gives permission to the patient to express what he feels. The therapist respects the patient by waiting on him with virtually unlimited, silent attention.

Projective statements encourage the real possibility of exchange, with a reciprocal attitude of generosity and freedom. They avoid the threatening effect of interrogation, which often sparks a negative transference.

This form of interpersonal language provides a way to control an invasive patient. Counterassumptive statements are comments made by the therapist that unsettle unconscious assumptions the patient makes about the therapist, and does so in a way that does not open a debate about the issue.

Counterassumptives are often put in the form of a maxim or proverb, and said with a tone of voice that carries a warning. The source—common usage—depersonalizes the statement. Here’s an example: "Hope springs eternal," said with a mordant tone that warns the patient not to have much hope with regard to the subject at hand.

Such statements often draw on the skepticism our society has about psychotherapeutic work. When the patient clearly has a skeptical view of the therapist, the maxim "God heals and the doctor takes the fee," can support the patient’s skepticism, acknowledge the therapist’s limitations, and serve to undermine the patient’s contempt.

Another version of counterassumptive is the clinical self-depreciation, a mix of manipulation and genuine expressiveness. This is useful for throwing salt on the patient’s expectations, as it can remind both parties that there is no certainty in psychotherapy, any more than there is in science or art.

Psychotherapy is mutually subversive, since both therapist and patient project on one another. Counterprojective statements deal with what is being projected on the therapist. It does so using the feelings the patient manifests about the projection, to allow the patient to share hostile and other feelings.

Counterprojective statements recognize the presence of other people in the room, e.g. mother, father, siblings, as emanating from the patient’s mind, and in so doing, moves the patient’s attention from therapist to himself.

It does so without directly confronting the patient with his projection (which could rouse defenses). Rather it is oblique, and gives the patient freedom to express strong feelings. The result often is depression in the patient, as he takes back into himself the feelings he had projected out.

Both projective and counterprojective statements provide the opportunity to gain perspective on the patient’s historical experience and emotional investments that have been carried over into the present as a projection. This allows the patient to differentiate from structures internalized in the past, and provides freedom from the past.

This type of statement is most useful when there is an absence of perspective. It also can reduce transference to manageable proportions, which can help to stimulate narrative flow.

Performative statements are a way to defend the patient’s self. These statements are the type that perform an action simply by being spoken. They are used primarily, in our society, by priests, judges and kings—persons in recognized positions of authority whose societal role invests them with particular power.

The concept of performative statements is that of J.L Austin, who set down key elements for a statement to be performative:

• the person speaking the performative words must be appropriate (i.e. an authority figure)

• the procedure must be executed correctly

• the intentions must be clear and understood by those involved in the process

• sincerity and follow-through are essential

Examples of such statement are the wedding vows; the naming of a boat; bequest directives in a will; or a verbal bet. The man puts the ring on the woman’s finger; the king breaks the bottle against the prow; the testator designates an object to go to an individual; the bettor puts up his money. These are ways the performative words are followed through.

Performatives are used in psychotherapy when appraising or reckoning something; when commending or admiring; or when hoping or wishing for. These verdictive statements gain their force from the expertise of the therapist. For example, the patient feels despair; the performative response by the therapist gives him the right to hope.

When the patient takes back projections, the result is often depression, because the hostile feelings are now contained in the personality. These feelings can be bearable when shared by the therapist. Performative statements can be especially useful in such contexts.

Note how performative remarks are the opposite of counterprojective statements:

counterprojectives are aimed at projected figures; they point away from the patient; they express the patient’s negative feelings about the projection

performatives voice positive feelings toward the patient; and they are about the patient himself.

The power of performatives is based on the therapist’s authority and the patient’s need to be loved. Performatives evoke the need to be loved and transfer it, so that the patient discovers he is loved for what is real about him.

Performatives are especially useful when working with the supine patient. Such a patient needs to find something to believe in, so as to lessen the inner hostile criticism. The performative statement gives rise to self-love and self-respect that comes from discovering the self.

There is a danger with the use of performatives, that the therapist might impose his own ideals or condemnations on the patient. The proper purpose of such statements is not to imprison the patient further in a world not of his own making, but rather to give the patient the possibility of decision, and to increase his potential for fuller existence. Performatives used properly help to build the patient’s ego ideal, and the self is reshaped in the act of working toward the ego ideal.

Different patients require different types of initial language. For example, the absent, withdrawn patient requires empathic and performatives initially. By being sensitive to his language, the therapist can engineer the structure of therapy to translate his passion into what is clinically effective. For what the therapist can translate into effective action the patient can then use to construct a livable existence for himself.