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How Does Psychotherapy Work? More Complexly Than You Imagine

Thoughtful man on beach

The reason effective therapists have tons of education is that it is really hard to change. While some people during a painful or difficult time in their lives might benefit from simply having a supportive, thoughtful listener, when people are stuck, that just isn’t enough. Everyone who has ever mocked or trashed psychotherapy does so because they think that all therapy entails is talking about your feelings with another person. They assume they can get those same needs met talking to a friend, or thinking through a situation themselves.

As therapists, we have friends and family. When our friends and family are suffering, we often talk to them about what is going on. On a good day, with the right friend or family member, we can be a strong supportive listener, maybe even a solid advice-giver. What we can’t offer our friends and family, ever, is therapy. When we are with people in our lives, we may be able to set aside our own needs and desires, and think only about what is best for the other. But what we cannot do with people in our lives, and what we must be willing to do to enter a therapy paradigm with a client, is make ourselves, our psyches, available for their use. 

This is a complicated concept. Please allow me to build to the theory a step at a time.

Initial Treatment

In early phases of long-term relational therapies, there is a lot of supportive, validating listening. In the beginning, therapy looks a lot like people imagine therapy looks like. The client shares their experience, internal and external. They express feelings that have happened outside the room, in their lives, describing situations and relationships. The therapist is typically affirming and validating, working hard to hear the person’s suffering and grievances, learn about their fears and hopes, and how their distress and anxieties and angers present. 

Even in early phases of therapy, therapists will challenge clients to look at their experience from new perspectives, encouraging them to see their role in the struggles in their lives. In the beginning we do this with some caution, as we are attempting to build an alliance that we can use in later work to help support our client’s ego strength when the work gets dark and hard and sticky.

This stage in the treatment process can look a lot like a very smart and savvy friend, one who has the capacity to sit with very hard materiel without emotionally retreating or trying to lighten the mood, and who can put their own issues and perspectives aside to hear their friends needs without imposing their own needs or framework on the situation. But this phase of therapy, which typically lasts for almost 18 months, is absolutely only the very beginning. 

Is this beginning phase we certainly make efforts to dismantle structures inside the client that hurt their world view and harm their relationships. But the real work of therapy, the real work of change, can’t happen until we develop a line of communication with our client’s unconscious.

Unconscious Material Presents Itself in Sessions

“This is really great music, isn’t it”?

“She was such a bitch, wasn’t she”?

This is a fairly common sentence structure. We all know someone who uses these phrases from time to time. If you know someone who uses it regularly, then you probably already know there is something problematic with this sentence structure. It limits the options of the other person’s response. It almost forces an affirmative response. While someone could certainly disagree, they would have to go out of their way to do so. They would have to assume the speaker would put up a fight of sorts, as they didn’t just say how they felt about the music, or the woman; they also asked the other person to affirm their declaration.

The person who uses this type of phrasing regularly does so for psychologically relevant reasons. Since in this instance we don’t have more data on this speaker, we can’t say exactly what the relevance is. Do they have a need to control others in the conversation? Do they anxiously wish to limit the complexity of the conversation? Are they desperate to seek validation from others about their opinions?

When a client uses such a phrase in a therapy session, rather than agree or disagree with the client, as the speaker is attempting to force, the good therapist will use it as opportunity to unpack the meaning behind the phrasing. They will say things like “I am wondering why you asked that way? I am remembering that you used similar phrasing last week”. The client will insist it is meaningless, just a common way of speaking. The therapist will have already collected some thoughts on why they may phrase things with an attempt to limit/control/force a particular response, which they will likely be able to directly link to a salient aspect of the client’s childhood. This will likely make the client feel judged, or overly scrutinized. They may feel we are taking the session over with our own agenda, making them discuss an irrelevant tangent rather than whatever story they were telling us. 

What they don’t know yet it that those are the moments of real therapy. Those are the moments that are going to help transform their lives. Those are the moments when the unconscious patterns and dynamics that are negatively impacting their lives are going to slowly get untangled.

This was a linguistic example, of which there are many. But there are as many clues to one’s struggle as there are people. Some folks will mumble or speak so softly that people, including the therapist will have to ask them to repeat themselves all the time. Meaningful. Some folks will say “I don’t remember what we talked about last week” without knowing they are telling us something…maybe that the conversation was so disturbing they blocked it, or maybe that what we said in that conversation enraged them and they want to indirectly tell us they didn’t bother thinking about again, or any number of meaningful reasons. Some folks will glance at the clock every time the therapist speaks. Meaningful. Some will come late or miss or cancel or forget to pay or have to leave early. All meaningful.

So, by meaningful I don’t mean bad. I mean meaningful. These actions/behaviors/clues reveal information to the discerning mind. Many a client, and likely quite a few readers, at first will think this is the therapist “reading into” things, and fabricating meaning out of nothing. The therapist usually doesn’t bring up these noticings though until they have accumulated enough data and woven it into a developing theory to test out with the client. Once a client gets on board with using these types of clues, they will be able to offer many more points of data with their own random feelings and associations. 

One of the great complaints many of us can declare on any given day is “Why oh why do I keep doing this same stupid thing”. Session are rife with clues to answer this question, in the form of unconscious offerings. Once the client can see/feel/resonate with these random bits of materiel that surface throughout sessions, they can enter a radically more fruitful collaboration with the therapist.

“Is It Boring Listening to Peoples Problems All Day”?

Therapists get asked this a lot. The question assumes that people who go to therapy go there to complain. It assumes clients are just whining about their lives and not using sessions to think and feel their way through complex material so they can make shifts from their core in their approach to life, themselves and others. 

The question also assumes the therapist is engaged in passive listening, just taking in what the client is saying, relying on the client to untangle their own dilemma. In my own experience, when I am doing a good job as a therapist, my mind/psyche/system is high active. I am not simply listening to a story or complaint. I am tracking data from the session with everything I know about my client. I am noticing patterns and inconsistencies. I have bits of theory surfacing on the periphery of my consciousness that seem applicable to this client in this moment. I am wondering about how the story I am hearing might be linked to last week’s session, or recent incidents in their lives, or dynamics from their childhood. I am trying to open myself to unconscious communication from the client, in the form of associations and tangents, and feelings surfacing in me that are not in line with the story the client is telling me. This is hardy an environment for boredom to arise.

Tracking Unconscious Communication in a Session

If I start to become bored in a session, I consider it diagnostic. Sometimes a client will indeed bore me. That however is something that would then immediately interest me. Why am I feeling bored? What is happening in the session that is flattening out my emotional experience? What is the client doing/feeling that is draining their dialogue of life and liveliness? What might purpose it serve them in their own lives, or for them in this conversation for me to have lost interest? If a client is boring me then they likely are able to have that effect on others as well. Whether they know it or not, whatever is happening inside them that is dampening their emotional life enough to bore me is what I am there to help them with.

This isn’t only true about boredom. It is also true when I feel irritated, or excited, or insecure, or riveted, or serene, etc. Communication happens at many levels. Certainly, we communicate from our conscious selves to another person’s conscious self. But our unconscious is also a participant in all conversations. When I am “listening” in sessions, I am listening to what the client is intentionally/consciously telling my conscious self, but I am also trying to suss out what their unconscious is attempting to offer. The trick is that the client’s unconscious is trying to communicate with their therapist through two pathways: From the client’s unconscious to the therapist’s conscious mind, but also from the client’s unconscious self to the therapist’s unconscious self.

The Therapist as the Instrument: Countertransference

When Freud first coined the term Countertransference, he framed it as “noise in the machine”, with the machine being the therapist. He noted that for instance if the therapist had an overbearing mother, and a client behaved in a similar way, the therapist might have an unconscious reaction and find themselves feeling emotionally suffocated, or however they felt in response to their own mother. Obviously, this would interfere with the therapist’s ability to respond appropriately to the client and therefor would need to be identified and purged from the therapist’s unconscious. He saw feelings that surfaced in the therapist in response to the client to be residue of the therapist’s mind/life/experience that needed to be eliminated least it contaminated the work of understanding the client.

This is certainly something that happens, and is in large part why therapists should routinely be in their own therapy as well as clinical supervision. It is imperative that we be vigilantly aware of ourselves and our emotional responses so that we would quickly notice if our own psychological material were getting activated in a session. Truthfully though, this type of countertransference is rudimentary and fairly easy for the skilled clinician to recognize and get on top of.

The concept of countertransference was greatly expanded by Object Relations Theory, namely by Melanie Klein. Her predecessor Wilfred Bion then expanded further with how a therapist might use countertransference, not as “noise in the machine”, but rather as listening device in session.

Klein postulated that the reason a parent holding an inconsolable infant starts to become flooded with panic and feelings of overwhelmed-ness, is not just a reaction to the crying infant. She argued that it was because those feelings of panic and overwhelmed-ness, which she coined “nameless dread”, were actually what the infant was feeling. She theorized that in part as a means of evacuation, and in part in an attempt to communicate, the infant projects out those feelings which are then absorbed by the unconscious of the sufficiently attuned parent. 

This process doesn’t stop in infancy, nor is it confined to the parent/child relationship. Some people are “better” as transmitting their emotional resonance to others and some folks are better at receiving it. In modern lexicon we sometime call either of these “empaths”. But all of us have had the experience of talking to someone and suddenly finding our internal mood quite changed, perhaps with feelings of inadequacy, or anxiety, or suddenly finding ourselves feeling sad when the other person wasn’t talking about sadness or talking about something that we could identify as having elicited sadness in us. The reason that happens is the feelings the other person transmitted to us were not conscious on their part. They might even imagine they are feeling quite the opposite. They might seem happy and jubilant while unconsciously communicating a deep, disavowed sadness that floods our unconscious.

What Wilfred Bion elucidated for the field of Object Relations Therapy is how as therapists we might finely tune our instrument to be able to receive these communications from our clients’ unconscious selves. Rather than rely simply on our minds to pick up clues and cues from what people said and did in sessions, he argued that we should be surveilling our own unconscious resonances for data from our clients.

Change is Hard

I suspect some of this sounds like mumbo jumbo psychobabble to some. Here is what I know. Change is really hard. Freeing oneself is hard. If all we needed was a good listener, a supportive shoulder, and some sound advice, then we could likely find a friend to offer us that. Psychotherapy exists in the realm of the unconscious. Our problems are not only practical; they are symbolic. All the information we need to untangle our suffering is available to us, though sometimes in code. Part of the data is emotional, and some of those emotions are ones we have forgotten, repressed, or disavowed, and yet they are imperative to unraveling the puzzle that is us. There is certainly a lot of good work that a client and therapist can do together at a conscious level. But the real work, the work that makes it worth devoting time and money and energy to psychotherapy, happens in the realm of the unconscious.

 

 

Smith is an analytically oriented psychotherapist with 25 years in practice. She is additionally the  Founder/Director of Full Living: A Psychotherapy Practice, which specializes in matching clients with seasoned clinicians in the Greater Philadelphia Area.

If you are interested in therapy and live in Philadelphia or the Greater Philadelphia Area, please let Full Living: A Psychotherapy Practice match you with a skilled, experienced psychotherapist based on needs and issues as well as personality and style.All of our therapists are available for telehealth conferencing by phone or video in response to our current need for social distancing. Request an Appointment Today.

If you were interested in this blog post, check out some of these:

Psychotherapists are like Dance Archeologists

Attending to the Unconscious in a Psychotherapy Session

Myths about Psychotherapy (a video blog)



Author
Full Living Founder and Director Karen L. Smith MSS, LCSW Karen L. Smith MSS LCSW Karen is the founder and director of Full Living: A Psychotherapy Practice, which provides thoughtful matches for clients seeking therapists in the Philadelphia Area. She provides analytically oriented psychotherapy, and offers education for other therapists seeking to deepen and enriching their work with object relation concepts.

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