Should your therapist scratch you where it doesn't itch?

Irvin Yalom, in his book Existential Psychotherapy, starts Chapter 2 (titled “Life, Death, and Anxiety”) by quoting the psychiatrist Adolph Meyer. The quote that Yalom includes is the following:

“Don’t scratch where it doesn’t itch.” 

This quote, Yalom points out, was presented by Meyer to groups of psychiatry students. It’s meant to advise clinicians to focus on the client’s own areas of concern. In other words, clinicians should only “scratch” where the client says there’s an “itch.” To do the opposite, to scratch where it doesn’t itch, risks wasting clients’ time and energy (at best) or actively doing them harm (at worst). 

Therefore, it’s best to stick to scratching only the areas that itch, right?

Irvin Yalom used this quote by Adolph Meyer to challenge it. Yalom zigs where Meyer zags and encourages therapists to scratch where it doesn't itch. And there is one particular “itch” that Yalom thinks therapists should reach for. This “itch” is the client’s awareness of death (mortality) and the anxiety about dying. 

Death, as a subject, is pretty overwhelming, isn't it? It's sometimes hard to even think about. It’s so overwhelming, in fact, that we sometimes deny that we're even going to die. We often tell ourselves that we are immortal.

Yalom agrees with all that and he thinks it stinks. He thinks that our denying our own inevitable death robs us of a deep, rich well of self-knowledge. By addressing our deaths, we can learn how to live more fulfilling, authentic, and meaningful lives. So go ahead and scratch your client's death anxiety itch, Yalom advises therapists, even if clients deny having such an itch. “Death,” Yalom writes, “itches all the time.” 

I love the book Existential Psychotherapy. It’s one of the most important and influential books in my education. I believe in Existential Psychotherapy. I see a profound truth in the idea that death anxiety and its denial animate much of our behavior as human beings.

However, I'm torn about “scratching where it doesn’t itch." On the one hand, I am sympathetic to Yalom’s perspective. On the other hand, I am devoted to practicing high-quality Solution Focused Therapy (SFT).

Solution-Focused Therapy (SFT) is often referred to as a "don't scratch where it doesn't itch" approach because of its focus on addressing current problems and finding solutions rather than delving deeply into past issues or exploring irrelevant details.

Here are a few reasons why SFT can be seen in this way:

1. Focus on Solutions: SFT is primarily concerned with helping clients identify and achieve their goals. Therapists using this approach do not spend much time exploring the root causes of problems or past traumas unless they are directly related to finding a solution. The therapy is future-oriented, aiming to create change in the present and future rather than dwelling on the past.

2. Efficiency: The approach is efficient in that it targets the specific issues that the client wants to change. Therapists using SFT believe that clients already have the strengths and resources to solve their problems; therefore, they focus on eliciting and amplifying these strengths rather than exploring unnecessary details.

3. Client-Centered: SFT is highly client-centered and collaborative. It respects the client's expertise in their own life and aims to empower them to find their own solutions. This contrasts with approaches that might assume the therapist knows best or that the client needs extensive analysis of past events.

4. Practicality: The therapy is practical and pragmatic, aiming to generate actionable steps that the client can take to move towards their goals. This practical approach means that therapists using SFT avoid theoretical discussions or therapeutic techniques that do not directly contribute to problem resolution.

In essence, SFT encourages therapists to focus directly on what the client wants to achieve in the here and now, rather than exploring issues or aspects of the client's life that are not directly relevant to creating positive change. This efficiency and goal-directedness are why it can be likened to a "don't scratch where it doesn't itch" approach—it doesn't waste time or energy on irrelevant areas but instead hones in on what will make a meaningful difference for the client.

In spite of the differences between their "scratch it" and "don't scratch it" approaches, I believe that Existential Psychotherapy and Solution Focused Therapy have much in common. Both approaches assist individuals in living more fulfilling, meaningful lives. Existential therapy approaches this by exploring themes of mortality. SFT does this by encouraging clients to imaginatively describe their preferred future.